Correctly billing your non-physician practitioner (NPP) services as incident to under your physician’s National Provider Identifier (NPI) number has various benefits to your practice. The most significant benefit of complying with incident to billing rules is that the services can be paid at 100% of the physician fee schedule (15% higher than billing directly under the NPP’s NPI).
With that said, the amount of money you are reimbursed should play no part in your decision whether to bill NPP services as incident to or not. This is especially true when your NPP provides the initial office visit to a new patient.
Even when your physician documents that they were present and immediately available during an NPP’s initial history and physical exam, it isn’t enough. Incident to billing rules require physicians to provide the initial patient service (including the history, physical and treatment plan). This allows the provider to establish a physician-patient relationship.
To correctly comply with incident to billing guidelines, it’s essential that you understand all of Medicare criteria and precisely what “direct supervision” really means.
Incident to Criteria
Based on CMS’ incident to billing rules, an office visit qualifies when it is “… furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”
Failing to consider this when billing incident to services will undoubtedly get you paid more, but it can also expose you to audits, fraud allegations, and hefty fines.
In addition to the physician being required to provide the first visit, CMS incident to billing rules also includes the following circumstances for an NPP visit to qualify:
- Must be a necessary part of patient care that is “incidental” to the services provided by the physician.
- Must NOT be included in claims submitted by the physician or regularly provided for free.
- Must be care that is commonly offered in an office or clinic.
- Must be under the “direct supervision” of a physician.
A common mistake when trying to comply with incident to billing rules is failing to realize that both the non-physician practitioner AND the physician must be credentialed and approved as Medicare providers. The Office of the Inspector General’s website is full of practices that had to pay thousands in penalties for billing incident to a physician’s care when the NPP was not a Medicare provider.
Note: You can find additional information on incident to and related supervision requirements in the CMS Internet-Only Manual (IOM) Publication 100-02, Chapter 15, Section 60.
What is Direct Supervision?
Pinning down what is and isn’t considered “direct supervision” under incident to billing rules isn’t always easy. You might think it means that the physician must be physically present in the exact same room as the NPP during the exam. However, this is not the case.
In fact, the Medicare definition of direct supervision states, “…does not mean that the physician must be present in the same room…”. Instead, for a service to qualify for incident to, the physician should be in the office and “immediately available to provide assistance and direction” during the entire time the NPP is providing care.
Note: Hospital and skilled nursing facility services cannot be billed as “incident to” at any time.
This post contains a small portion of the requirements that you must comply with to bill NPP services as incident to correctly. Mastering these confusing and complex rules is the only way for your NPP services to receive payment at the full physician fee schedule rate. For more in-depth advice and step-by-step strategies to ethically boost your NPP reimbursement, check out the upcoming online training, Get Paid 15% More for NPP Supervised Services, New Rules Apply, presented by Leslie Boles, BA, CCS, CPC, CPMA, CHC, CPC-I, CRC, on Wednesday, June 15, 2022, 1 pm ET.
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