Incident-to FAQs

Below are questions and answers in regards to key billing incident-to services in rheumatology practices.

What is incident-to billing?

“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 the physician’s office. If the criteria are met, the service should be billed under the physician’s national provider number (NPI) and the practice receives 100% of the physician’s fee schedule for the service. Keep in mind, incident-to services are only applicable to Medicare.

Who qualifies as an NPP to bill incident-to services?

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), a nurse practitioner (NP), a clinical nurse specialist (CNS) or an advanced practice registered nurse (APRN), etc., and their scope of practice as defined under state law must allow providing “incident to” services.

What is direct supervision?

Direct supervision means the physician must be in the office suite and can immediately be available to provide assistance if needed.

What services can a NPP bill incident-to?

An NPP can bill for all services allowed within their scope of practice. In order for a service to qualify as incident-to billing, the patient must be an established patient with an established diagnosis or condition.

Can an NPP bill an incident-to claim for a new patient?

No, a patient new to the office would not have been seen by the physician; and consequently there wouldn’t be a physician-initiated plan of care. The patient would not be under the physician's 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% of the physician fee schedule.

Would an established patient with a new problem be able to be seen by an NPP?

Yes, but the NPP would not be able to bill this as incident-to. The new complaint would not be in the physician’s plan of care and so it would not meet the criteria for being billable as an incident to service. The NPP could address the patient’s new problem but they would need to bill under their own NPI and receive 85% of the physician’s fee schedule rate.

What is a 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 NPP’s assessment of the established problem, and the physician must document the assessment of the new problem separately.

How can I determine what services would be covered under a nurse practitioner’s scope of practice?

It is important for practices to check the physician assistant national organization’s website, www.aapc.com, to find the contact information for the association in your state.

Does incident-to billing apply to private carriers?

Incident-to services are only applicable for charges billed to a Medicare contractor. You will have to verify with each private carrier on how to bill for services performed by an NPP.