Editor’s Note: We are excited to announce that this article is the first of a series addressing Medicare Part B’s “incident to” billing requirements, designed to give practical guidance and orientation to health care providers, compliance officers, billing managers, and entrepreneurs alike. We will be addressing various common and unique “incident to” questions in upcoming articles and welcome feedback on areas of interest.
In this first article, we set forth the general “incident to” billing requirements, in order to set the groundwork for the series. Note that this article reviews requirements to bill “incident to” a physician’s professional services in an office setting.
Medicare Part B allows a physician (or certain other non-physician practitioners) to maximize their productivity by receiving reimbursement for certain services furnished by “auxiliary personnel” on an “incident to” basis.
Note that the ability to utilize “incident to” billing is subject to various requirements and limitations. The “incident to” requirements are set forth in (sometimes contradictory or at least hard to reconcile) federal regulations, Medicare billing policies, and subregulatory guidance issued by local Medical Administrative Contractors (MACs). Failure to comply with the “incident to” rules can lead to issues ranging from claims denials, overpayments, being placed on pre- and/or post-payment review or even false claims liability (with a lookback or statute of limitations of up to ten years).
Physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, clinical psychologists, clinical social workers, physical therapists and occupational therapists, also known as Non-Physician Practitioners (NPPs) have their own Medicare coverage categories, and can bill and provide professional services independently, subject to state law. For example, NPPs may provide professional services without direct physician supervision (subject to state law) and bill directly for these services. Services performed and billed directly by NPPs are reimbursed at a lower rate (85% of the Physician Fee Schedule rate for those services when performed by physicians). However, when an NPP’s services are provided as “auxiliary personnel”, they may be covered as “incident to” services, in which case the “incident to” requirements would apply. Services provided “incident to” a physician’s professional services are reimbursed at 100% of the Physician Fee Schedule rate for the identified physician service.
For purposes of the physician “incident to” regulations, “auxiliary personnel” means any individual who is acting under the supervision of a physician (or other eligible practitioner), regardless of whether the individual is an employee, leased employee, or independent contractor of the physician (or other practitioner) or of the same entity that employs or contracts with the physician (or other practitioner), has not been excluded from the Medicare, Medicaid and all other federally funded health care programs by the Office of Inspector General or had his or her Medicare enrollment revoked, and meets any applicable requirements to provide “incident to” services, including licensure, imposed by the State in which the services are being furnished.
In later articles, we will be addressing the conditions under which an NPP may provide services “incident to” another NPP.
“Incident to” a physician’s professional services means that 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. The services must relate to an existing course of treatment; the “incident to” rules do not apply to a new patient or when treating an existing patient for a new illness or injury.
To be covered “incident to” the services of a physician, Chapter 15, Section 60 of the Medicare Benefit Policy Manual (Manual) and the “incident to” regulations set forth that the services and supplies must be:
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Foley is here to help you address the short- and long-term impacts in the wake of regulatory changes. We have the resources to help you navigate these and other important legal considerations related to business operations and industry-specific issues. Please reach out to the authors, your Foley relationship partner, or to our Health Care Practice Group with any questions.