Master Incident-to Billing With This Comprehensive Guide

Posted on 26 Feb, 2019 |comments_icon 0|By Bruce Pegg

If, like most practices, you have a nurse practitioner (NP) or other nonphysician practitioners (NPPs) on staff, and you aren’t billing incident-to for some of the services they perform, then not only are you leaving money on the table, but you’re also negatively affecting your practice’s ability to run smoothly and effectively.

But before you change your billing practices and fall foul of Medicare or private payer incident-to billing guidelines, you’d best make sure you know what those guidelines are and how to implement them correctly. Take a few minutes to review the ones we’ve listed below and see how to do it — or how you should be doing it.

What is Incident-to Billing?

You can bill incident to when integral services or supplies that are a part of a physician’s plan of care for a particular patient are provided by an NPP working incidentally to the physician. (Incidental, in this sense, means minor or of lesser consequence, not acting by chance!)

Note: Incident-to billing is a Medicare convention. While “incident-to” is regarded as Medicare terminology, many payers in certain states, including Aetna, Health America, Cigna, United, adopt Medicare rules when services are furnished this way.

However, private payers’ rules may differ from Medicare’s, so be sure you understand each payer’s contract before submitting this kind of claim. 

Why Should You Bill Like This?

By billing services incident to the provider, you could bring 15 percent more reimbursement into your practice for an NPP’s services. When services meet the criteria outlined later in this post, you can bill them under the physician’s name and national provider identifier (NPI) and receive a higher reimbursement rate than billing the service under the NPP. Medicare normally pays incident-to claims at 100 percent, whereas they usually reimburse claims billed under the NPP’s NPI at 85 percent.

If you can’t report the service incident to the physician, because the services don’t meet the criteria below, that doesn’t mean you can’t bill for the NPP’s services. Rather, it means you can’t bill incident to the physician. You do still have the option to direct bill under the NPP’s own NPI number. Keep in mind that even if incident-to billing is not an option, there are other benefits to using NPPs. Not only might your office be able to move some patient services to the NPP, allowing your provider to accommodate more patients, but the provider may also be freed from the burden of taking care of the paperwork associated with those services.

What Guidelines Need to Be Followed When You Bill Incident-to?

Once you’ve determined that incident-to billing is appropriate for your practice, you’ll need to become familiar with Medicare and other payers’ guidelines and follow them to a T. Here are four of the most important.

1. Only NPPs can bill incident to the physician.

So, who qualifies as an NPP? NPPs come in all sorts of roles. They could be physician assistants (PAs); certified registered nurse practitioners (CRNPs), such as midwives or anesthetists; advanced practice registered nurses (APRNs); clinical nurse specialists (CNSs); clinical social workers (CSWs, or LCSWs); clinical psychologists (CPs); physical or occupational therapists; and NPs.

To add to the alphabet soup, you might also refer to an NPP by some other common acronyms, including APP (advance practice provider), LLP (limited license practitioner), or MLP (mid-level provider).

2. The physician must provide direct supervision.

To bill a service incident to the physician, the NPP must be under direct supervision. Direct supervision means more than simply having a supervising physician overseeing the patient’s plan of care. The physician must also be physically available (i.e. in the practice or office suite) to treat the patient at the time of the service. This means that the supervising provider must be close enough to be able to provide care for the patient should an emergency situation arise, such as the patient going into anaphylactic shock after an NPP administers an allergy injection ordered by the provider.

3. Only report certain services incident to.

Only services that require direct supervision qualify to be billed incident to. So, flu shots. certain lab and radiology services, and EKG services should not be billed this way. Additionally, because NPPs must be executing a plan of care that was previously established by the physician, NPPs cannot bill new patient services or encounters for new problems as incident to. Other services that you cannot bill as incident to include new patient evaluation and management (E/M) and preventive services and consultations such as:

  • 99201-99205Office or other outpatient visit for the evaluation and management of a new patient …
  • 99241-99245Office consultation for a new or established patient …
  • 99381-99387Initial comprehensive preventive medicine evaluation and management of an individual …
  • 99391-99397Periodic comprehensive preventive medicine reevaluation and management of an individual ….

4. Ensure proper documentation.

Aside from providing the kind of documentation usually required for any service a physician would provide for a patient (such as the service being medically appropriate and necessary), CMS regulations require you to document that the services are also:

  • An integral part of the patient’s treatment course;
  • Commonly rendered without charge (i.e. services included in your physician’s bills);
  • Of a type commonly furnished in a physician’s office or clinic (i.e. not provided in an institutional setting);
  • An expense to you (i.e. care that represents a direct financial expense to the practice).

Payers will also probably require documentation of the patient’s initial visit, including documentation that the physician, and not an NPP, performed the primary physical exam and history and created the patient’s care plan during that visit.

While not required in most instances, the physician should sign off on the incident-to encounter to show that he is still actively engaged in the patient’s care plan. Should any problems arise during the encounter with the NPP, such as in the anaphylactic shock scenario mentioned earlier, the physician must sign the record and indicate whether the problem has resulted in a care plan modification.

Last, but not least, the NPP’s name and credentials must appear in the record along with the documentation of direct supervision on the physician’s part.

Contributing editor: Chris Boucher

Learn More

The newly updated best-selling Nonphysician Practitioner Handbook 2019 helps you master your NPP coding, billing, compliance, and documentation challenges with step-by-step guidance from industry experts to earn the revenue you deserve.


Bruce Pegg
Editor, Newsletters

An experienced teacher and published author, Bruce is TCI’s new voice of primary care, delivering advice and insights every month for coders in the fields of family, internal, and pediatric medicine through Primary Care Coding Alert and Pediatric Coding Alert. Additionally, he is the current editor of E/M Coding Alert. Bruce has a Bachelor of Arts degree from Loughborough University in England and a Master of Arts degree from The College at Brockport, State University of New York. He recently became a Certified Professional Coder (CPC®), credentialed through AAPC.

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