Incident-to Billing and Non-physician Practitioners

Incident-to Billing and Non-physician Practitioners
By Guest Contributor Jean Acevedo, LHRM, CPC, CHC, CENTC, AAPC Fellow
President and Senior Consultant of Acevedo Consulting Incorporated

Physicians have been billing under Medicare’s incident to benefit for years; that’s how they have been paid for the nurse’s injections, infusion services and other physician services personally provided by a clinical staff member.  The claim goes out as if the supervising physician personally provided the service, and that’s appropriate as the medical assistant or registered nurse is not considered a qualified health care professional who can bill on her own. Understanding the incident to requirements has taken on increased importance as non-physician practitioners (NPPs) such as Physician Assistants (PAs) and Advanced Registered Nurse Practitioners (ARNPs) have begun to work in practices with increasing frequency.

This importance is primarily due to the following two factors.   First, the NPP can and must enroll in the Medicare program1  and consequently has his/her own Medicare number to bill the program directly.  Second, the Medicare reimbursement for a NPP is 85% of the physician’s payment, therefore, physicians understandably want to bill the NPP’s services as incident to their own so as not to lose 15% of their charges.  However, if the incident to billing requirements are not met or well documented, the physician could find him/herself in the unpleasant situation of having an overpayment assessed.

Incident to Requirements
To qualify as “incident to,” services must be part of the patient’s normal course of treatment, during which a physician in the practice personally performed an initial service and remains actively involved in the course of treatment2. The physician does not have to be physically present in the patient’s treatment room while these services are provided, but must provide direct supervision, that is, a physician in the group must be present in the office suite to render assistance, if necessary. The patient record should document the essential requirements for an incident to service.

More specifically, these services must meet all of the following:
•  The services/supplies are an integral although incidental part of the physician’s professional services and established treatment plan;
•  The services/supplies are of a type that are commonly furnished in a physician’s office or clinic;
•  The services/supplies are furnished under the physician’s direct personal supervision; and
•  The services/supplies are furnished by an individual who qualifies as an employee (W2, 1099) of the physician’s practice.

The Confusion

Anecdotally, it appears that confusion and misunderstanding as to when it is permissible to bill an ARNP’s or PA’s services as if the physician personally provided the service stems from the disconnect between the NPP’s scope of practice (which may require just general supervision) and that of incident to billing (which requires direct supervision – billing physician in the office suite).   It is common for a PA or ARNP to say “When I’m seeing a patient I don’t need a doctor in the office to supervise me.”  From their licensure perspective, that is accurate, and Medicare would agree, but would add that, when no physician is in the office suite, the services provided by an NPP must be billed under their name and NPI.

Understanding that when Medicare says the services must be “part of the physician’s professional service,” means there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the non-physician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician's continuing active participation in and management of the course of treatment3. Yes, of course, a PA or ARNP can create their own plan of treatment, change the dose of a medication started by the physician, order an x-ray, etc.   However, the moment the NPP makes independent treatment decisions, they are no longer just following the physician’s plan of treatment and services must now be billed to Medicare under the NPP’s name and NPI.   

•  Question:  If an established patient presents to the office for a visit with a non-physician practitioner (NPP), and during the encounter the patient has a new problem/condition, can this service be submitted 'incident to'? What if the NPP only orders tests, but does not establish a plan of care?
•  Answer:  No, there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment. This service must be submitted under the NPP’s NPI number. A service cannot be submitted 'incident to' even when the NPP only orders diagnostic or laboratory tests, unless the physician provides a face-to-face encounter and establishes the course of treatment (e.g., need for X-ray, apply ice, etc.) during the encounter (must be documented by the physician).

Final Thoughts

It must be noted that this article is discussing only the Medicare requirements for incident to billing.   As more non-physician practitioners begin working in practices it is imperative that other payer policies be checked.  Some insurers, such as Florida Blue, do not allow any NPP incident to billing.   Modifier –SA must be added to Evaluation & Management services on a claim when they are provided by an ARNP or PA and billed as the supervising physician to United Health Care.  Physicians billing commercial plans must therefore review their provider contracts and health plan rules to determine whether billing the services of one provider under the name and NPI of another provider is allowed – and if so, under what  circumstances – or whether it’s forbidden.

There is a very real compliance risk if a physician bills under the doctor’s NPI as if all incident to billing requirements were met when they did not.  Although we no longer see a CMS 1500 claim form, the doctor’s signature on the claim still attests that s/he personally provided or personally supervised the services and that all of the information on the claim is accurate and correct.   In 2017 there were several cases of physician’s being charged with alleged false claims because claims were submitted to Medicare or other payers with the physician’s name and NPI as the rendering provider when the services were personally performed by a NPP yet either the doctor was not in the office when the patient was seen, had not previously seen the patient, or, the NPP changed the doctor’s treatment plan.  One of the many examples is a family practice physician in 2017 who paid $133,880.50 under the Civil Monetary Penalties Law for submitting claims to Medicare for nurse practitioner services as if he had personally performed the services when all the incident to requirements had not been met.

Non-physician practitioners can be great assets for rheumatologists by increasing access to care, allowing the physician to see more new patients and consultations while the NPP provides routine follow up visits.  Just like any other new venture, however, the physician and practice manager must take the time to research the criteria for doing it the right way.  In the case of NPPs and incident to billing, that means checking the State regulations for the ARNP’s or PA’s scope of practice as well as Medicare’s4  and other payers’ billing rules.

1 SupEnroll
2 CMS MLN Matters Number: SE0441
3 CMS Internet Only Manual Publication 100-2, Chapter 15, Section 60.2
4 Products/APNPA.html


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