The Quick Guide to Incident To Billing
by Cheryl Nash
Given the growing frequency of commercial and Medicare audits, it is becoming increasingly important to ensure your billing is accurate. Adding a mid-level practitioner can be a great benefit to a growing phlebology practice. By knowing the basic rules of the road you can be sure your billing practices will pass the test.
If you have a PA or NP, you know most of their services are billed ‘Incident To’. So what does Incident To mean? 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).’ [MLN MATTERS SE0441] The claims are billed under the Physician’s NPI number and are paid under the same physician fee schedule.
There are several scenarios for when it is correct to bill under the supervising providers NPI, and when it is correct to bill under the NPP’s NPI number.
The first questions you need to ask yourself is ‘who is diagnosing the patient’ and ‘who is setting the course of care’?
When a physician provides the initial service, makes a diagnosis and creates the care plan, and remains actively involved and provides direct supervision (available in the office suite), then the services qualify as Incident To as long as it is a part of the patient’s normal course of treatment.
For Phlebology practices, where services are typically provided in the doctor’s office suite, the services must be provided by a practitioner who you directly supervise, and pay for their services as a direct financial expense (e.g., you provide them a W-2 or 1099 form at the end of the year). You do not need to be in the same treatment room when these services are provided, but you do need to be directly available. For Medicare this usually means you need to be in the office, and for most commercial payers, this means you need to be available by phone, and close enough that you can be in the suite if needed. As always, state licensures and individual payers have differing guidelines. Be sure to check yours.
In a scenario where the NP or PA is the diagnosing provider, then the service must be billed under the NP or PA’s NPI as the rendering provider. This is true for both new patient visits, or an established patient that presents with a new problem not currently being treated in your office. The reimbursement is typically 85% of the Physician fee schedule for these services.
Other examples of services typically performed by NP or PA can be physical examination, minor surgery, setting casts for simple fractures, interpreting X-rays and other activities that involve an independent evaluation or treatment of the patient’s condition. Also, if authorized under the scope of their state license, NPs/CNSs may furnish services billed under all levels of evaluation and management codes and diagnostic tests if furnished in collaboration with a physician.
For a Phlebology practice minor surgery is typically defined as a service that does not exceed a 10 day global period, such as sclerotherapy, or needle aspiration of a hematoma. Again, only services permitted to be performed by state law should be performed, or will be covered by insurance.
Additional resources for Incident To billing guidelines can be found at cms.gov or under your local MAC (Medicare Administrative Contractor) websites, usually under ‘Billing for NPP Services’, or under ‘Incident-To’.
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