We often get questions about incident-to billing, especially since the rules were updated in 2026.
But before we get into the updates, let’s make sure we’re on the same page…
What is Incident-To?
“Incident to” is a Medicare Part B billing provision that allows services performed by non-physician practitioners to be billed under a supervising physician’s National Provider Identifier (NPI), when certain requirements are met.
Providers whose services may be billed incident-to include Nurse Practitioners, Physician Assistants, Certified Nurse Midwives, and Clinical Nurse Specialists.
Notably, a service provided, for example, by an NP, but billed incident-to under the physician NPI, is eligible for reimbursement at 100% of the physician rate.
However, the same service provided under the NP’s own NPI will only be reimbursed at 85% of the allowable (remember that incident-to is a Medicare billing provision).
The only exception is Oregon, which reimburses NPs on par with physicians at 100%.
Required Conditions for Incident-To
To qualify for incident-to billing, a few conditions must be met, as outlined in 42 CFR 410.26.
- Setting: The service must not be provided in an institutional setting, such as a hospital or a skilled nursing facility.
- Not standalone: The service must be an integral part of the physician’s service in the course of diagnosis or treatment, and cannot be a standalone service a patient asks for.
- Supervision: A qualified professional or physician must directly supervise the staff, except in certain areas that require only general supervision.
- Initial Exam/Service: The physician must have performed the initial service or exam and must remain actively involved over the course of treatment.
- Common Service: The service must typically be provided in an office setting, without a separate charge.
- State Law and Scope of Practice: The service furnished must be included in the scope of practice of the supervised provider and permitted under state law.
- Employment Relationship: The NP (or other professional) providing the service must be an employee of the office or organization, or must have some contractual relationship with the physician or group.
What Has Changed?
Not much…
The most significant change is how direct supervision is now defined.
According to CMS, direct supervision means the supervising provider must be immediately available via real-time audio and visual interactive telecommunications. However, the supervising provider no longer must be physically present in the same office suite.
Be aware that audio-only communication is not part of the new definition and does not count.
Concluding this Brief Update on Incident-To…
To use incident-to billing, the NP must be employed by, or have some form of contractual relationship with, a clinic or medical office.
To qualify for incident-to billing, the NP must follow up on an established problem after a physician diagnosed it.
If the patient alerts the NP to a new problem and wants to be treated for it, incident-to billing can no longer be used.
In all likelihood, incident-to billing cannot be used in an NP-owned practice for the reasons above.
What’s your experience with incident-to billing…? Tell us in the comment section below.
By Johanna Hofmann, MBA, MAc., regular contributor to the NPBusiness blog.