Billing for ‘incident to’ services
By Marc Sencer, MD

Take this short quiz to assess your knowledge of an integrated-practice “basic.” The question may have more than one correct answer, which means the usual test-taking tricks won’t help! Either you know the answer — or you don’t!

You have been advised correctly by your healthcare attorney and consultant that you may bill services for physical therapy as “incident to” the services of a medical doctor on your staff. This means the medical doctor will be listed on the claim as the provider of the service.

Which of the following is the correct way to bill physical therapy services incident to a medical doctor?

A. For Medicare and private insurance reimbursement, a massage therapist or athletic trainer may apply the therapy as long as the MD is in the office.

B. For incident-to services, the MD does not have to be in the office as long as he or she is providing supervision within a reasonable distance, is constantly available by telephone, and performs a chart review.

C. For Medicare and private insurance reimbursement, only a licensed physical therapist may actually apply the therapy, even though it is done as incident to the services of an MD.

D. In some cases it may be acceptable to have an unlicensed physical therapist perform the therapy on Medicare patients.

“Incident to” billing is a complex topic, and several related issues come into play when attempting to bill physical ther-apy services as incident to the services of a medical doctor in your group.

The correct answer is D. Medicare will reimburse for the services of an unlicensed physical therapist working incident to an MD, provided the therapist has completed all of the training requirements for licensure. This means the PT has all of the training prerequisites to sit for the exam, but has not taken or has not passed the exam.

If you are planning to use an unlicensed therapist and bill incident to services of your MD, be aware that the above only applies to Medicare reimbursement. Your state Board of Physical Therapy may not allow an unlicensed PT to practice, even with the MD’s supervision.

In addition, some insurance plans stipulate in their contracts that they will only reimburse for the services of a licensed PT.

B is incorrect, because for services to be billed incident to those of an MD, the doctor must be on the premises when services are rendered. This is true no matter who the payer is, and it is not restricted to Medicare patients. Billing for incident-to services when the MD is not present in the office suite is fraudulent.

A and C are incorrect, because as of November 2004 Medicare will not reimburse for therapy services provided by athletic trainers and massage therapists incident to those of an MD.

Medicare will reimburse for therapy services performed incident to services of an MD, if they are performed by a nurse-practitioner, physician’s assistant, or certified nurse specialist. Remember that these restrictions apply to reimbursement for Medicare patients only, and in most cases do not apply to other third-party payers.

A is also incorrect for another important reason: If you bill incident-to services, it is not enough for the doctor to be on site. The patient receiving the services must be a patient in treatment with that doctor. The doctor must have seen the patient at least once before, and that the services being billed are part of the doctor’s treatment plan. Remember that incident-to means much more than just “billing under a doctor’s license.”

Marc H. Sencer, MD, is the president and founder of MDs for DCs, which provides intensive one-on-one training, medical staffing, and ongoing practice-management support to chiropractic integrated practices. He can be reached at 800-916-1462 or www.mdsfordcs.com.