We recently held a webinar on billing nonphysician practitioner (NPP) services incident to the physician. And you wouldn’t believe the number of questions that came out of that session.

This is certainly not a new topic, but there continues to be a great deal of confusion surrounding it. And many of the questions had to do with “direct supervision” and exactly what that means for billing purposes. This is so important because the Centers for Medicare and Medicaid Services (CMS) requires the physician to provide “direct supervision” of the incident-to service. And that’s the cause of most of the uncertainty.

CMS says that direct supervision means the physician must be present in the office suite to render assistance. But an office suite can be many things considering all the different places where practitioners provide care. So let’s examine a few to see how incident-to works in each:

• Your Practice — This is probably the location where incident-to services are most straightforward. Although you don’t have to be in the room with the patient while your NPP is providing incident-to care, you do have to be present in the office suite. This is mainly so that you will be able to provide assistance if the patient or NPP requires it.

One more point about Incident-to in the office setting: Any physician in your group practice may be present in the office to supervise, even if the patient isn’t theirs. As long as there is a physician in the office suite who can provide assistance, then you can bill the services as incident-to. On the other hand, if you’re a solo practitioner, then you must directly supervise the care.

• In the Hospital or Skilled Nursing Facility (SNF) — You can’t bill incident-to services in the inpatient setting, CMS says. You bill inpatient services provided in the hospital or SNF under Medicare Part A, which covers all care provided in those locations. So any incident-to services are included as part of the care package reimbursed under Part A and can’t be billed separately.
• Your Practice Located in an Institution — This setting can get particularly confusing because of the potential for care patients to be covered by a Part A event. First, if your practice is located in an institution, such as a section of a hospital or SNF, then it must be confined to a separately identifiable area for you to bill services as incident-to. It “cannot be construed to extend throughout the entire facility,” CMS says.

Further, your NPPs can provide incident-to services only to outpatients. That means you can’t bill any services provided to those who are in the facility under Part A as incident-to, even if you see them in your office suite.

• In Patients’ Homes — If your NPP is providing services in a patient’s home, then you have to be present in the home as well to bill the services as incident-to. There are some exceptions, however, if the patient is homebound and lives in a medically underserved area where there are no available home health services. If this is the case, you must still order the services, maintain contact with the NPP, and retain professional responsibility for the services.
• In an Ambulance — You cannot bill services performed in the ambulance or by emergency medical technicians as incident-to, even if you provide telephone supervision to the caregivers, CMS says.

If you find that you can’t bill a service as incident-to, remember that you can still bill the service under the NPP’s national provider identifier (NPI). Just keep in mind that you will only be paid 85% of what you would receive if you had billed the same service incident to the physician.

Take Aways:

• Any physician can provide supervision for NPPs to bill incident-to services, even if the patient is not that physician’s. It’s the fact that the NPP has supervision that’s important.
• You don’t have to be in the room with the patient to provide direct supervision, but you do have to be within the office suite.
• You can always report an NPP’s services under their own NPI is there’s no physician to provide supervision, but you won’t be paid as much.