Billing Basics For ‘Incident-To’ Services

1
Billing Basics For Incident-To Services
2
Billing Basics For Incident-To Services

• Defining Incident to
• Incident-to services are usually initiated by a
  physician and provided by a non-physician
  provider (NPP) following the care plan and
  supervision of the physician. The physician must
  be physically present in the office suite and the
  services provided must be commonly performed in
  the physicians office. If the criteria are met,
  the service should be billed under the
  physicians national provider number (NPI) and
  the practice receives 100 percent of the
  physicians fee schedule for the service. Note
  that, incident-to services are only applicable to
  Medicare. Incident-to services are only
  applicable for charges billed to a Medicare
  contractor. You will have to verify with each
  private insurance carrier on how to bill for
  services performed by an NPP.
• Billing Requirements for Incident-to Services
• As discussed above, incident-to billing applies
  only to Medicare and, the incident-to billing
  does not apply to services with their own benefit
  category. Diagnostic tests, for example, are
  subject to their own coverage requirements.
• The service billed incident to must take place in
  a noninstitutional setting, which the Centers
  for Medicare Medicaid Services (CMS) defines as
  all settings other than a hospital or skilled
  nursing facility. Hospital services incident to
  physicians or other practitioners services
  rendered to outpatients (including drugs and
  biologicals which are not usually
  self-administered by the patient), and partial
  hospitalization services incident to such
  services may also be covered.

3
Billing Basics For Incident-To Services

• Incident to services cannot be rendered on the
  patients first visit, or if a change to the plan
  of care occurs. A Medicare-credentialed physician
  must initiate the patients care. If the patient
  has a new or worsened complaint, a physician must
  conduct an initial evaluation and management
  (E/M) service for that complaint and must
  establish the diagnosis and plan of care.
• Subsequent to the encounter during which the
  physician establishes at a diagnosis and
  initiates the plan of care, an NPP may provide
  follow-up care under the direct supervision of
  a qualified provider.
• A physician must actively participate in and
  manage the patients course of treatment. This
  requirement typically is defined by individual
  state licensure rules for physician supervision
  of NPPs.
• Both the credentialed physician and the qualified
  NPP providing the incident to service must be
  employed by the group entity billing for the
  service. If the physician is a sole practitioner,
  the physician must employ the NPP.
• The incident to service must be of a type usually
  performed in the office setting and must be part
  of the normal course of treatment of a diagnosis
  or illness.
• Billing Basics for Incident-to Services
• Eligible NPP An NPP is a non-physician provider
  who must meet supervision requirements in order
  to provide incident to services and to receive
  appropriate compensation for the physician. NPPS
  can be a physician assistant (PA), nurse
  practitioner (NP), clinical nurse specialist
  (CNS), or advanced practice registered nurse
  (APRN), etc., and their scope of practice as
  defined under state law must allow providing
  incident to services

4
Billing Basics For Incident-To Services

• New patient A patient new to the office would
  not have been seen by the physician, and
  consequently there wouldnt be a
  physician-initiated plan of care. The patient
  would not be under the physicians supervision.
  So, if the NPP evaluates and treats the new
  patient without an initial visit with the
  physician, then he or she will have to bill the
  services under their NPI number and receive
  reimbursement at 85 percent of the physician fee
  schedule.
• Established Patient The NPP would not be able to
  bill established patient, this as incident-to.
  The new complaint would not be in the physicians
  plan of care and so it would not meet the
  criteria for being billable as an incident to
  service. The NPP could address the patients new
  problem but they would need to bill under their
  own NPI and receive 85 percent of the physicians
  fee schedule rate.
• Direct supervision means the physician must be in
  the office suite and can immediately be available
  to provide assistance if needed.
• Shared/split visit A shared/split visit is when
  both the physician and the NPP share a visit in
  treating the patient. This is now allowed for
  outpatient services such as office visits. Both
  the physician and NPP must independently document
  their part of the visit. For example, an
  established patient presents with a new problem
  along with an established problem and is being
  seen by the NPP. The NPP can call in the
  physician to assess the new problem but the
  documentation must include the NPPs assessment
  of the established problem, and the physician
  must document the assessment of the new problem
  separately.

5
Billing Basics For Incident-To Services
Accurate billing and coding backup by proper
documentation will reimburse all your
Incident-to services. Most of the time,
practice owners are unaware of different billing
scenarios in Incident-to services and end up
receiving claim denials. Medisys Data Solutions
can assist you in medical billing for your
rheumatology practice including Incident-to
services. Our expert medical billers and coders
are well versed with billing guidelines and
billing scenarios and ensure accurate insurance
reimbursements for delivered services. To know
more about our rheumatology billing and coding
services, contact us at info_at_medisysdata.com /
302-261-9187
6
(No Transcript)