How to fulfill Medicare’s “incident-to” billing requirements.
A great deal of confusion surrounds the procedures for “incident-to” billing among both medical doctors and chiropractors. Inaccurate ideas abound and many practices are not billing correctly. To properly process this billing designation, master these firm guidelines that you can take to the bank with confidence.
“Incident-to billing” is defined as billing for medical services supervised by a physician but performed by someone else. Generally, the person performing the service is a nurse practitioner, a physician assistant, or a certified nurse specialist. Other caregivers such as psychologists might be involved.
The physician’s supervision must be direct, which means he or she is required to be on-site while the service is being performed. On-site means in the building or suite, but not necessarily in the room during treatment.
“Incident to” is a Medicare concept and applies to Medicare billing. Some private payers follow the Medicare guidelines, and others have their own policies or do not recognize any form of incident-to billing. Verify the policy of each payer you work with.
Incident-to billed services are those that are part of a physician’s day-to-day practice. This rule indicates the doctor should follow up periodically with the ongoing treatment of the patient. The Centers for Medicare and Medicaid Services (CMS) does not specify any specific length or frequency for these follow-up visits, so for most conditions that are stable, a level 2 visit and note in the chart should suffice.
The supervising physician is only allowed to bill existing patients and problems using incident to. This means the supervising doctor must see every new patient personally and, if the extender sees an established patient for a new problem, the visit cannot be billed as incident to. Instead, the physician will have to see the patient initially for the new problem.
When a doctor is unable to bill for incident-to services with a Medicare patient, he or she must bill using the extender’s NPI number with the extender as the provider. Medicare will automatically reimburse at 85 percent of the fee schedule as opposed to 100 percent for incident-to services.
Navigating the maze
For private payers, it’s a little more complicated. If the medical doctor acting as the supervising party is off-site and the payer credentials the extender, the service is billed under the extender. If the payer does not credential the extender, however, the service can be billed under the supervising doctor. Given that the doctor overseeing operations is on-site, the service may be billed under the supervising practitioner, provided the payer allows incident-to billing.
If more than one physician is participating in the care of the patient, you may bill the services incident to the ordering physician if he or she is not on-site, as long as another supervising practitioner is present.
Although incident-to billing is a federal issue, some state regulations apply when you are billing for rehabilitation or physical therapy services. In most states, physical therapy assistants (PTAs) may perform physical therapy services billed under a physical therapist (PT) when the PT is off-site (indirect supervision).
Some states require direct supervision as defined above. In addition, at least one state (Florida) stipulates that only a PT, an orthopedic surgeon, a physical medicine and rehabilitation MD, or a chiropractor can supervise a PTA.
Lastly, state boards and, increasingly, payers are taking the position that when billing incident to an MD, the person actually performing the therapy must be licensed and qualified to do so. More insurers want to know who performed the therapy and are denying claims for services performed under MD supervision by a massage therapist or someone other than a PT, or PTA under PT supervision.
Because Medicare and some private payers will pay more for services billed incident to, you should thoroughly understand the rules of the game. Incident-to billing comes under increased scrutiny by payers, so you must do it correctly to reap the benefits.
Marc H. Sencer, MD, is the president 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 through mdsfordcs.com.