Medicare’s incident-to billing can feel like a minefield. But understanding it can pay off — quite literally. When done right, it allows practices to bill mid-level provider services at physician rates, which can increase reimbursement by 15%. So, how does it work?
Understanding Incident-To Services
Incident-to billing applies when services provided by non-physician practitioners (NPPs) are billed under a physician's National Provider Identifier (NPI) number. This enables the practice to receive reimbursement at 100% of the physician fee schedule instead of the 85% typically applied to NPP services. Sounds great, right? But there are specific criteria to meet.
Key Requirements
The requirements for billing incident-to services are nuanced. They include:
Initial Encounter: The physician must initiate the patient’s care. This means the physician has conducted the first visit and established a care plan. If the NPP sees a new patient or deals with an issue outside the initial care plan, the service does not qualify for incident-to billing.
Direct Supervision: The supervising physician must be physically present in the same office suite and immediately available to provide assistance. Note — this doesn’t mean they need to be in the same room, but they must be on-site.
Ongoing Involvement: The physician must continue to be actively involved in the patient's care. This doesn’t mean attending every visit, but they should see the patient periodically and reaffirm the care plan.
Employment Status: The NPP must be an employee, leased employee, or independent contractor of the physician or practice. Freelancers need not apply.
Ignoring any of these rules can lead to denials or, worse, audits and penalties.
Supervision Rules Explained
Direct supervision is a frequent stumbling block. Misunderstanding what “immediately available” means can be costly. Medicare requires the physician to be in the same office suite. Telehealth doesn’t cut it here — even in our increasingly remote world.
And remember, every payer isn’t Medicare. Some commercial payers have different supervision requirements, so always check specific payer policies. If UnitedHealthcare mandates different rules, follow them when billing their claims — not Medicare’s.
Billing NPP Services at Physician Rates
When incident-to requirements are met, billing becomes a straightforward process. Use the physician’s NPI on the CMS-1500 form and document the physician's involvement in the care plan. This documentation is crucial — it’s your evidence if Medicare questions the billing.
But beware of the pitfalls. If a service doesn’t meet all incident-to criteria, bill it under the NPP’s NPI at the 85% rate. Don’t try to sneak it through under the physician’s NPI. Medicare audits can be relentless, and penalties for improper billing can outweigh any short-term gains.
Practical Tips for Managing Incident-To Billing
Documentation Is Your Shield
When it comes to incident-to, thorough documentation isn’t just advisable — it’s essential. Record the physician's initial plan, subsequent involvement, and supervision during each visit. Electronic Health Records (EHR) can streamline this, but ensure staff knows how to input the right data.
Train Your Staff
Billing teams and NPPs should understand incident-to rules inside out. Regular training sessions help, especially with Medicare updates (which are as regular as clockwork).
Monitor Payer Policies
It’s not uncommon for private payers to have unique policies regarding incident-to billing. Keep a spreadsheet or database of each payer’s requirements, and update it regularly. This prevents nasty surprises when reimbursement isn’t what you expected.
Watch for State Regulations
State-specific regulations can further complicate incident-to billing. For example, some states have additional supervision requirements for NPPs. Ignoring these could mean billing at the lower rate or facing compliance issues. Keep abreast of your state's regulations as they evolve.
The Bottom Line
Incident-to billing, when done right, is a boon. It allows practices to maximize revenue from NPP services. But vigilance is essential. Know the rules, follow them to the letter, and keep meticulous records. Cutting corners isn’t worth the risk — Medicare will find out. Embrace the complexity, manage it well, and watch how it supports your practice’s bottom line.
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