Clarify Incident-to Billing


If your practice is like many others, you are likely staffing with a majority of mid-level providers. The reason for doing so may encompass several scenarios, such as difficulties in finding and attracting physicians to lower staffing costs of operations. One thing is certain, electing staff with nurse practitioners or physician assistants brings certain challenges when it comes to submitting claims for patient care.

Many practices that employ mid-levels to provide patient care believe “incorrectly†that since they have a physician providing oversight AND since that same physician is usually also contracted and credentialled under the facility’s managed care contracts that it is perfectly acceptable to bill for the patient’s care, provided by the mid-level under the supervising physician’s PIN or NPI number. They mistakenly consider this care (and subsequent claim submission) to fall under the practice of incident-to billing.

The danger for both practitioner and organization is that this is NOT a correct utilization of the incident-to protocol and could result not only in a claim denial, but worse, if continued submission of claims occurs, this could result in fraud, fines, and loss of contracts with the payer(s).

So, what is the correct use of incident-to billing and how can your organization avoid submitting claims incorrectly when utilizing mid-level practitioners? Let’s start with the Medicare (CMS) definition of an incident-to billing situation:

                Incident to is defined as services or supplies that are furnished incident to a physician’s professional services when the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness and services are performed in the physician’s office or in the patient’s home. To qualify for payment under the incident to rules, services must be part of the patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the ongoing course of treatment. (CMS, February 02, 2019, Internet Manual Publication 100-02, Chapter 15, Section 60. Revision 256.)

Before we dive into what that definition really means, let’s review a couple more important definitions:

  1. Immediately Available. This term is important when used in reference incident-to billing, “immediately available†refers to the fact that the physician (in this case the one that you are going to be billing the claim under) is readily accessible and present, without delay, on-premises. This does not mean that the physician can be available by phone or other technology, or that he/she can make their way to the facility within a short, acceptable amount of time.
  2. Direct Supervision is a trickier term when it comes to defining how it is related to the incident-to doctrine. Notably, direct supervision does not imply that the mid-level’s supervising physician be physically present while the NP (and of course this refers to CP, CNM, CNS, or PA) provides evaluation and care, but rather that they must be present in the facility and immediately available to provide assistance and direction throughout the entire time the mid-level is providing the services.

Many have incorrectly assumed that Direct Supervision means that the physician has had to take part in the evaluation or treatment provided. Hence the “direct†portion of the term. But as noted above, this is simply a clarification of the Immediately available rule and in fact, any physician, not necessarily the documented supervising or collaborating physician, can be the practitioner who provides the direct supervision in order to comply with incident-to guidelines.

Putting more clarity to what defines a situation for incident-to billing. Essentially, the patient must be receiving care for an on-going condition in which the physician provided the initial evaluation and care. Basically, the mid-level provider is carrying out the treatment plan that was already established by the patient’s original physician while providing a current evaluation and follow-up. In fact, if we consider incident-to billing in an urgent care setting, these services primarily performed are related to evaluating and treating episodic conditions and does not include the establishment of a physician providing an initial evaluation and care plan.  Given those facts, it’s generally obvious that incident-to conditions cannot be met.

A couple of more items to be wary of before you consider utilizing incident-to billing. :

  1. Your mid-level must be an employee of the physician or entity. Things can get even more complicated with incident-to billing if the mid-level is a locum or an interdependent contractor.
  2. Utilization of a mid-level to provide care is not an end-all staffing solution. It is expected that the physician remains active in the on-going care of the patient, providing subsequent evaluations and treatment at a frequency appropriate to manage the patient’s condition and care. This cannot be a situation wherein the physician makes an initial appearance and then essentially hand’s off care to the mid-level.

In summary, billing for a patient being seen by a mid-level is going to be based in general upon the following:

In closing, remember that while Medicare certainly sets a standard for incident-to billing and reimbursement, individual payer contracts may vary from payer to payer and from region to region. Be sure to review each of your payor contracts and billing guidelines for specific language regarding mid-level reimbursement.

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