AVOIDING INCIDENT WITH INCIDENT TO BILLING

Whenever I am asked if an encounter qualifies for Incident To Billing, I always respond with “let me review the Medical Record first”. Generally, that is received with a few groans and some eyeball rolls, but it is a strongly suggested step in determining if the service provided is supported by Medicare (CMS) and local Medicare Administrative Carrier (MAC) guidelines. I have put together a variety of Tools from around the internet, from trusted resources, including CMS to share with you and help you determine if your practice is billing this type of service correctly.

The first thing to remember is that Incident To Services are defined by CMS as: “Incident to” services are defined as those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution*) or in a patient’s home.

(*The only exception to this is when the physician establishes an office within a nursing home or other institution. Where a physician establishes an office within a nursing home or other institution, coverage of services and supplies furnished in the office must be determined in accordance with the incident-to a physician’s professional service provision as in any physician’s office. A physician’s office within an institution must be confined to a separately identified part of the facility which is used solely as the physician’s office and cannot be construed to extend throughout the entire institution. Thus, services performed outside the office area would be subject to the coverage rules applicable to services furnished outside the office setting.do not qualify in any type of Facility setting, ever).

https://medicare.fcso.com/faqs/144538.asp

BILLING EXAMPLE OF 100% REIMBURSEMENT:

If we look at this example, we see that a Medicare patient has returned for a follow up visit for their Pacemaker and is seen in the office by a Nurse Practitioner (ARNP), the ARNP supervised this visit and followed behind the Plan of Care (POC), which was initially established by the group’s Cardiologist. The ARNP documents how the patient has been progressing, along with any new or resolved complaints. There is another Cardiologist in the office that day (satisfies “office suite-contiguous requirement”), so he/she, is considered the Supervising Physician. This suffices the CMS requirement for Direct Supervision and thus the visit should qualify for Incident To billing, as long as all Medicare requirements are fulfilled, enabling the clinic to be reimbursed at 100% of the Medicare physician fee schedule.

BILLING EXAMPLE OF 85% REIMBURSEMENT:

In this second example, the Medicare patient is returning for a follow up visit and advises the ARNP, of a new complaint of Left Hip Pain, which is unrelated to the prior visit for his Pacemaker. The ARNP, may address the new complaint and outline a new treatment plan, but Incident To would not be met, it would be billed under the ARNP’s NPI and will be reimbursed at 85% of the CMS fee schedule for their state/local MAC. Since it was a new complaint, Incident To is not met under the CMS guidelines and can’t be used with a new complaint.

From the AAPC article on “The 7 Requirements to Incident To”: Per the CMS Benefit Policy Manual:

1. Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.
2. If auxiliary personnel perform services outside the office setting, e.g., in a patient’s home or in an institution (other than hospital or SNF), their services are covered incident to a physician’s service only if there is direct supervision by the physician [e.g., the physician must be physically present to oversee the care].
3. Any physician member of the group may be present in the office to supervise. The supervising physician does not have to be the physician who performed the initial patient evaluation.
4. A physician must actively participate in and manage the patient’s course of treatment. This requirement typically is defined by individual state licensure rules for physician supervision of NPPs.
5. Both the credentialed physician and the qualified NPP providing the incident-to service must be employed by the group entity billing for the service. If the physician is a sole practitioner, the physician must employ the NPP.
6. The incident-to service must be of a type usually performed in an office setting and must be part of the normal course of treatment of a diagnosis or illness. The Benefit Policy Manual explains, “Where supplies are clearly of a type a physician is not expected to have on hand in his/her office or where services are of a type not considered medically appropriate to provide in the office setting, they would not be covered under the incident to provision.”
7. Services meeting all the above requirements may be billed under the supervising physician’s NPI, as if the physician personally performed the service. Documentation should detail who performed the service, and that a supervision physician was in the office suite at the time of the service. https://www.aapc.com/blog/44912-seven-incident-to-billing-requirements/

Q & A FROM First Coast Service Options (MAC for FL, PR, USVI) CMS – ON INCIDENT TO: 

3Q: If a new patient comes into the office and sees our physician assistant (PA), can our PA bill this as incident-to the physician, who is also in the office seeing patients?

3A: No. For the service to qualify as incident-to, an initial encounter must have occurred between the physician and the patient, and a course of treatment established by the physician. In this situation, services performed by the PA do not meet the incident-to requirement and would not qualify because this is a new patient. The claim would be billed listing the PA as the performing provider.   Link to FCSO Guidance: https://medicare.fcso.com/faqs/144538.asp FCSO also has an Incident To decision tool – FIRST COAST SERVICE OPTIONS (FCSO) CMS MAC FOR FL, PR, USVI– INCIDENT TO TOOL: https://tools.fcsomedicare.com/apps/incidents

TOOLS:

Below is an Incident To Knowledge Grid, designed by Betsy Nicoletti, MS, CPC for her 2024 article with FPM (Family Practice Management) and the AAFP (American Academy of Family Practitioners), on Incident To: (link to grid is below Image)

https://www.aafp.org/pubs/fpm/issues/2024/0500/shared-services-billing.html

Below is an Incident To Billing Tip Sheet from the University of Chicago: (link to tip sheet is below image)

https://compliance.bsd.uchicago.edu/Documents/NPP%20BILLING%20TIP%20SHEET.PDF

TIPS:

• Incident-to claims that do not meet Medicare rules are potentially false claims. Such claims are punishable by the Department of Justice and the Office of the Inspector General (OIG).
• When considering use of “incident to” billing, I strongly suggest reviewing all Payer contracts, CMS & Medicare Advantage for their respective Incident To billing requirements for proper claim submission and reimbursement

RESOURCES:

1. CMS MLN NATIONAL GUIDELINES: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf
2. CMS PHYSICAN FEE SCHEDULES AND INCIDENT TO SERVICES: https://www.cms.gov/medicare/payment/fee-schedules/physician-fee-schedule/advanced-practice-providers/incident-services-supplies
3. AAPC SEVEN INCIDENT TO BILLING REQUIREMENTS: https://www.aapc.com/blog/44912-seven-incident-to-billing-requirements/