Healthcare Fraud Shield’s Latest Article: Understanding Incident to Services

5 Feb

Here is a little test to see how much you know about “incident to” services:

1) Dr. Geriatric is a physician with many patients at the Sunset Hills Nursing Home.  He sends his physician assistant each week to evaluate his patients, order and review lab tests, and write orders of care.  Both he and his physician assistant get together each Saturday to go over updates on each patient, and Dr. Geriatric then co-signs the orders and encounter notes. (Is this an example of correctly applying incident to guidelines for billing?  Yes Or No?)
2) Dr. Jones has been looking forward to taking his family to Disney World this summer and has informed his patients that his physician assistant will be seeing them in his stead while he is gone.  (Is this an example of correctly applying incident to guidelines for billing?  Yes  Or No?)

How did you do?  Go to the end of this article for the answers to this quiz.  Then, let’s do a bit of a review on incident to.

According the Centers for Medicare and Medicaid, “incident to” services are defined as services or supplies 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.”[i]  The physician must first see the patient initially as an Evaluation and Management (E/M) service to determine a diagnosis and document a plan-of-care (POC).  Then a non-physician under the supervision of the physician (such as a Nurse practitioner, or Physician’s Assistant) can carry out the prescribed treatment on subsequent patient encounters for the course of that treatment.  These services must meet all of the following criteria[ii] to qualify as incident to:

  • An integral part of the patient’s treatment course;
  • Commonly rendered without charge (included in a physician’s bill);
  • Of a type commonly furnished in a physician’s office or clinic (not in an institutional setting); and,
  • An expense to the physician (must be an employee of the supervising physician).

As the subsequent encounters are an extension of the physician’s prescribed treatment plan for the patient, the services are billed under the physician’s provider ID and reimbursed at 100% of the physician fee schedule.
So you might be wondering, if there are other requirements for billing incident to services.  And yes, there are.  Below is a handy “Fact Sheet” for billing Incident to.

1)  The physician must have provided a previous E/M service, determined a diagnosis, and documented a plan of care (POC).  ONLY the documented plan of care is applicable to incident to billing.  (Any deviation or additional services make the encounter no longer incident to.)
2) Incident to services require direct supervision:  This means that the physician must be 1) physicallyin the office, and 2) immediately available.[iii]  (Direct supervision, does not mean the physician must be standing next to the patient, or in the same room.)
3) Availability by phone does not meet incident to criteria for direct supervision.
4) This applies to therapeutic services and supplies on an outpatient basis (including the use of hospital facilities and drugs and biologicals that cannot be self-administered).  Diagnostic services cannot be billed as incident to.
5)  Place of service (POS):  Incident to services may be billed in the office, clinic, emergency room, and observation settings.  (Policies for hospital outpatient therapeutic services furnished incident to physicians’ services differ in some respects from policies that pertain to “incident to” services furnished in office and physician-directed clinic settings.  See Chapter 15, “Covered Medical and Other Health Services,” Section 60.[iv] for details.)
6) Incident to cannot be billed in an in-patient or outpatient hospital setting,  or skilled nursing facility. (Incident to applies only to non-institutional settings.)
7) The physician does not need to see the patient each time, but must see the patient subsequently for services of a frequency  that reflects active participation in the patient’s care (in other words, the physician does not hand-off the patient care to the non-physician, but continues to see the patient over time).
8)  When there is a change in the POC, it is no longer considered incident to.
9) Incident to services must be billed under the supervising physician’s provider ID, and are reimbursed at 100% of the physician fee schedule.
10) Types of services commonly billed as incident to include:  E/M services; minor surgery; chemotherapy; setting casts; professional component of radiology services; and office visits.
What about billing incident to services for the home-bound patient?   Generally, a non-physician visiting a home-bound patient must bill under their own provider ID and reimbursement is 85% of the physician fee schedule.  However, if the patient is in a medically underserved area where there are no available home health services, CMS has set criteria for incident to billing.  See Pub 100-02, Chapter 15 Section 60.4 (B)[v] for guidance.
Answers to the Incident to quiz
1)No. Incident to cannot be billed in the skilled nursing setting.  In addition, Dr. Geriatric does not meet the direct supervision requirements of incident to.
2) No. A physician assistant cannot bill under the supervising physician’s provider ID in his absence.  As the physician is not physically in the building, and not immediately available, the physician assistant must bill under his/her own provider ID.  Services will be reimbursed at the 85% physician fee schedule.
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