BLOG / By Keisha Wilson
Author: Keisha Wilson CCS, CPC, CRC, CPB, CPMA, AAPC Approved Instructor
Incidents to Services and Split Shared Services often need clarification for many. Our last article, “Split or Shared Services in 2023”, detailed what Split Shared Services are. This article will discuss Incidents to Services, guidelines, and providers that can bill for the services. 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. Incidents to services are submitted under the physician’s NPI but are performed by an NPP (Non-Physician Practitioner) or other qualified healthcare practitioners.
The incident-to-services must occur in a non-institutional setting. Rules allow services that meet incident-to requirements to be paid at 100% under the physician’s NPI and reimbursed for non-physician services(Services and Supplies Furnished Incident To a Physician’s/NPP’s Professional Service). But if services furnished by an NPP that do not meet the incident requirements are paid at 85% reimbursement under the NPP NPI number. Note, Incident to services applies only to Medicare.
Incidents to services must be part of the patient’s regular course of treatment, during which a physician personally performs an initial plan of care and remains actively involved in the course of treatment. The NPP or other qualified professionals performs subsequent and follow-up services. The follow-up visits are for an established patient with an established plan of care that the NPP follows. A physician does not have to be personally present in the exam room with the NPP and patient while these services are provided, but they must provide direct supervision; that is, the physician must be present in the office suite to render assistance, if necessary.
If a physician is a solo practitioner, they must directly supervise the care. If a part of a physician group, any physician member of the group may be present in the office to supervise. The patient record should document the essential requirements for the incident to service and include the supervising physician.
Incidents to services are also relevant to services supervised by certain nonphysician practitioners such as:
- Physician assistants
- Nurse practitioners
- Clinical nurse specialists
- Nurse midwives
- Clinical psychologists
Incidents to services must include the following:
- An integral part of the patient’s treatment course
- Commonly rendered without charge (included in your physician’s bills)
- Of a type commonly furnished in a physician’s office or clinic (not in an institutional setting)
- Furnished by the physician or by auxiliary personnel under the physician’s direct supervision
- Employed by the physician or group practice (such as a “W-2” or leased employee or an independent contractor).
When is the incident to services not applicable:
- A new patient visits
- A visit by an established patient who presents with a new problem. Visits with established patients who are experiencing new problems require active physician participation and cannot be billed on an incident to basis
- Services provided by a resident
- When the physician and the NPP are in different locations (Physician in the hospital doing rounds and NPP in the office suite seeing the patient)
- Below PDF are great examples given by NGS on the incident to services and which practitioner services should be billed under
An office (POS 11) is limited to the dedicated area or suite designated by records of ownership, rent or other agreement with the owner. The supervising physician or practitioner maintains their practice or provides their services as part of a multi-speciality clinic.
Hospital and Skilled Nursing Facility
Per CMS, for inpatient or outpatient hospital services and services to residents in a Part A covered stay in a SNF, the unbundling provision provides that payment for all services are made to the hospital or SNF by a Medicare intermediary (except for certain professional services personally performed by physicians and other allied health professionals). Therefore, incidents to services are not separately billable to the carrier or payable under the physician fee schedule.
In Patients’ Home
You must be present in the patient’s home for the service to qualify as an “incident to” service. Some exceptions to this direct supervision requirement apply to homebound patients in medically underserved areas where there are no available home health services only for certain limited services found in Pub 100-02, Chapter 15 Section 60.4 (B). In this instance, you need not be physically present in the home when the service is performed, although general supervision of the service is required. All other incident requirements must be met. Additional rules apply for incident-to-billing of physician’s services in a clinic and services incident to a physician’s service to homebound patients under general physician supervision.
Incident to services requires direct supervision by the supervising physician, who must be present in the office suite and immediately available and able to provide assistance and direction throughout the service. The supervising physician does not have to be in the same room but must be in the office suite.
Medicare covers services rendered to homebound patients provided by non-physician practitioners under direct personal supervision when the following criteria are met:
- The service is an integral part of the physician’s/nonphysician practitioner’s services to the patient
- The services are included in the physician-directed clinic’s, physician’s/nonphysician practitioner’s bill, and the services represent an expense to the clinic or physician/nonphysician practitioner.
- The services are reasonable and necessary and not otherwise excluded from Medicare coverage.
Documentation should follow current coding guidelines (2021 or 2023 Evaluation & Management), including Chief Complaint, History and/or Exam and Medical Decision Making. Documentation should include a physician’s initial care plan and any medication adjustment at subsequent visits. Documentation from other dates of service, both initial and subsequent, should establish a link between the two providers.
Per NGS FAQ, a physician’s initial plan of care may include prescription medication that may require adjustment on subsequent visits; the need for medication adjustment does not represent a “new problem.” Therefore, an NPP may bill these visits as incident to the original plan of care when the physician includes that instruction in the original plan. An example: “Have started patient on Losartan 100 mg. po qd for BP 160/90; patient to RTO in two weeks for f/u. NP may adjust the dosage on f/u visits.”
Medicare does not currently require the supervising/billing physician to sign off on the services of the non-physician practitioner/ancillary staff. However, for workflow and to make tracking easier, the signature of the treating providers should be documented along with the signature of the NPP performing the service. Documentation should contain evidence that the physician was actively involved in the patient’s care and was present and readily available during the encounter.
Understanding your payor policies and the guidelines for reporting incidents to services is imperative. Continue to train the providers, NPP, clinical and billing staff on the rules and stay abreast of all the changes with continued training.
To schedule training on documentation and coding guidelines of Split or Shared services for your organization or private practice providers, email us today at firstname.lastname@example.org, schedule a call or visit the website and fill out the “contact us” form.