Clarifying incident-to billing

Q:Incident-to billing is confusing and our practice is unclear on how and when it should be used appropriately. What guidance can you provide?

A: First, I think we need to remember some of the basic incident-to requirements. According to the Centers for Medicare and Medicaid Services (CMS) MLN Matters No. SE0441, for services performed in the office, qualifying “incident-to” services must be provided by a caregiver whom the physician directly supervises, and who represents a direct financial expense to the physician (such as a “W-2” or leased employee, or an independent contractor).

To qualify as “incident to,” services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. The physician does not have to be physically present in the patient’s treatment room while these services are provided, but he or she must provide direct supervision , meaning the physician must be present in the office suite to render assistance, if necessary.

If you are a solo practitioner, you must directly supervise the care. If you are in a group, any physician member of the group may be present in the office to supervise.

NEXT: if a physician bills incident-to when nurse practioner performs the service, does NP have to be credentialed with insurance company?

Q:If a physician bills incident-to when a nurse practitioner (NP) actually performs the service, does the NP have to be credentialed with the insurance company of the patient?

A: Health and Human Services has recently clarified that a physician can function as an extender under the direct supervision of another physician. As a result, it would be permissible to report services performed by a non-credentialed physician under the name of a credentialed physician when all the incident-to requirements have been met .

However, if you choose not to credential your non-physician provider (NPP) with Medicare in order to bill services incident-to, you need to be careful. Scenarios outside your NPP’s control could render a service non-billable.

For example, a patient comes in for treatment of a condition for which the physician established the plan of care. However, the patient tells the NPP that she threw out her back and would like it examined and treated. Since the back issue is a new problem, the NPP cannot bill under the physician’s provider number. Therefore, it must be billed under the NPP’s provider number. Unless the NPP is credentialed with a payer, the patient visit cannot be billed.

In addition, there must be direct, on-premise supervision by a credentialed physician for the NPP to bill for a patient visit. In group practices, this might not be a problem, because a physician nearly always is on-site. However, in a small office with fewer physicians or a sole practitioner’s office, if a physician is not in the office suite and directly available for NPP support, this could also result in a non-billable service.

I want to caution that the services of a physician that has been excluded from cannot be reported under the name of a credentialed physician using the incident-to rule on discussed above. Federal regulations prohibit any provider or entity that submits claims to the federal government from employing an excluded provider and reporting services performed by the excluded provider for payment.

The answers to the readers’ questions were provided by Renee Dowling, a billing and coding consultant with VEI Consulting in Indianapolis, Indiana. Send your billing and coding questions to medec@advanstar.com.