NPBusinessShowPodcast Incident To Billing npbusiness.org/26

Billing Incident-To? Here are the Rules – NPBS26

Does the idea of Incident To billing leave you perplexed? Are you working with individuals who insist that all your visited be billed out as incident-to? Well, this is what we are going to talk about today on the NPBusiness Show podcast.

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Incident-To Billing

Incident-to billing can be confusing.  Unfortunately, many NPs find their employers want to bill under incident-to, yet there is often a mis-understanding of this issue, as we’ve talked about before. The problem is it can potentially result in fraud charges if the rules are not followed.

Define (as per CMS): “Incident to” services are defined as those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home. These services are billed as Part B services to your carrier as if you personally provided them, and are paid under the physician fee schedule.

Allowable Discount: 15% to NPs and PAs. For example, if MD is allowed $100, NPs/PAs are allowed $85.

Rules:

  • First of all the visit takes place in the office.
  • The physician must perform the initial service and continue to be actively involved in the course of treatment.
  • The NP or PA sees the patient in follow-up for the identified problem and follows the plan of care.
  • The physician MUST be in the office suite at the time the visit takes place, not necessarily in the exam room, but in the office incase “direct” supervision is required.
  • The documentation needs to reflect the essential requirements for an incident to services.
  • The NP or PA must be an employee or what medicare refers to as a “leased employee” or an “independent contractor” that is paid for by the physician and practice.

Other

Note: “Incident to” services are also relevant to services supervised by certain non-physician practitioners such as physician assistants, nurse practitioners, clinical nurse specialists, nurse midwives, or clinical psychologists. These services are subject to the same requirements as physician-supervised services. Remember that “incident services” supervised by non-physician practitioners are reimbursed at 85 percent of the physician fee schedule. For clarity’s sake, this article will refer to “physician” services as inclusive of non-physician practitioners.
CMS Documentation: http://go.cms.gov/1Y3xJ8H (shortened)

Your Turn

What’s your experience with incident-to billing?

Comments 8

  1. I teach coding and billing and focus on”incident to” billing. I have heard it all when it comes to creative ways to bill for NP services. The NP needs to ask how the practice intends to bill for NP services. Never assume it is being done correctly. The NP is responsible for what is billed. Once you know you are being billed “incident to” and the practice refuses to change…you need to leave as you are liable.

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  3. Is there any difference in Incident To billing rule for NP/PA providers in the Rural Health Clinic setting as compared to Fee for Service settings?

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  5. “Incident to” billing is invisible billing for NPs. If you agree to bill incident to a physician collaborator your work is not counted. Strongly advise NPs to not accept a position where their physician employer takes credit for their work.

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  7. Barbara,
    What is the other options for billing Medicare by NPs? Just billing fee for service using the NPs Medicare number and taking the 85% rate? Looking for clarification on this. What about Medicare plans like Kaiser Permanente?

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    Leslie,

    The Medicare rates for NPs are 85% until it is changed on a federal level. Most Medicare advantage plans (in my experience) follow the Medicare allowable for your location, with a 15% discount for NPs and PAs. I have never contracted with Kaiser Medicare, you would have to contact them and find out what their current practice is.

    Good luck and thanks for stopping by!

    Barbara

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