"Incident To" Billing FAQs

“Incident to” services are services that are performed by a non-physician practitioner (NPP) and can be billed to Medicare. To qualify as “incident to” services, Medicare requires certain regulations be followed. Below you will find some frequently asked questions in reference to billing for “incident to” services. These specific rules are only for Medicare. Providers should inquire with their private third-party payers regarding billing for “incident to” services.

1. Who is considered a non-physician practitioner under “incident to”?
   
   The following non-physician practitioners would be permitted to perform services “incident to” the physician’s service and be reimbursed:
   
   1) Physical or occupational therapist;
   2) Certified registered nurse anesthetist;
   3) Physician assistant;
   4) Clinical nurse specialist;
   5) Advanced registered nurse practitioner; and
   6) Technicians

2. Does a physician need to see the patient first prior to an NPP providing “incident to” services?
   
   Yes. A physician must see and evaluate a patient for the initial visit to the office under “incident to” rules. The physician is required to perform the initial service and subsequent services frequently enough to reflect the physician’s active participation in and management of the patient’s course of treatment. Future NPP incidental services do not have to coincide with a service provided by the doctor, as long as the physician’s subsequent services are of a “frequency that reflects the doctor’s continuing active participation in and management of the course of treatment”.
   
   Medicare policy does not specifically address if an NPP can see an established patient with a new illness or injury. However, it may be practical to avoid having a non-physician diagnose a patient without the help of a physician, since there is no specific direction from CMS on the matter.

3. Under Medicare “incident to” services are required to be provided under the “direct supervision of a physician. What is considered “direct supervision”?
   
   “Direct supervision” does not mean the doctor has to be in the same room with the non-physician practitioner while the service is being performed. Medicare does require the physician be “present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”

4. Does the ordering physician need to be in the office suite when services are performed “incident to”?
   
   No. If the ordering physician is out of the office when the NPP sees a patient, another physician in the same group can provide the direct supervision required. The practice must ensure the CMS-1500 form is filled out correctly to indicate the name of the supervising physician as different from the ordering physician.

5. If a physical therapy assistant (PTA) is being supervised by a physical therapist (PT), and performing physical therapy in a physician’s office, can this service be billed as “incident to” under Medicare?
   
   No. If the PT and PTA are working in a free standing physical therapy office or clinic the PTA would bill under the PT’s NPI. However, in a physician’s office, the PT is required to perform the services and bill for them either under their own NPI or “incident to” the physician’s services.

6. In order to bill a service as “incident to” a PT would have to utilize they physician’s NPI number. Can a PT bill under his employer’s NPI number for “incident to” and also bill under his own NPI for non-“incident to” services?
   
   Yes. Physical therapists can switch back and forth between their own NPI and the physician’s NPI within the same practice. This usually occurs when a physician is present or not present in the office suite.

7. Can I bill for “incident to” services in a hospital setting?
   
   No. “Incident to” billing can not be used in a hospital for either inpatient nor outpatient services. The only exception to this would be if a physician is renting space from the hospital and has his or her own office there. Otherwise, “incident to” billing can only be used in a physician’s office.

8. Do I need to use a modifier to code for “incident to” services?
   
   No. Medicare does not require the use of a modifier for services billed by a physician that are covered as “incident to” a physician’s services.

9. Can only NPPs bill for “incident to” services?
   
   No. Physicians can also bill for “incident to” service in limited circumstances. For example, if a physician is new to a practice who is licensed but has not yet received their Medicare ID number, that physician can bill “incident to” another, Medicare approved, physician. The new physician could also wait until their Medicare ID is issued before submitting these claims.
   
   The “incident to” rules would need to be followed:

   • The physician without the Medicare ID must follow a plan of care established by a Medicare approved physician. They cannot bill for treating new patients or problems;
   • A physician with a Medicare ID must provide direct supervision;
   • The two physicians must be members of the same group practice, or at a minimum, have a fair-market value contractual relationship with a physician who is not employed by another group;
   • Services covered under separate provisions of Medicare law, such as diagnostic tests, cannot be billed “incident to”;
   • Since there is no billing for “incident to” services in a hospital or SNF, the physician billing “incident to” would not be permitted to make rounds; and
   • The physician whose ID goes on the claim is held liable by Medicare for the actions of the physician billing “incident to”.

10. Can I bill “incident to” service to private carriers?
    
    Physicians should check with their individual carriers in order to determine how “incident to” billing and billing for NPP services generally are handled. Rules may vary by carrier and by state. While some carriers may follow the Medicare regulations for such billing, there is no requirement that they do so.

For more information contact the Academy at (312) 464-9700 or wchill@aapmr.org.