Every organization strives for optimum efficiency and productivity. Healthcare is no exception.
Medical practices today face numerous challenges, including physician shortages and increasing patient loads, particularly as baby boomers age into their senior years. The demand for quality care is rising, yet resources are stretched thin.
One effective way to address this issue is to engage non-physician practitioners (NPPs) to support patient care. NPPs can ease the workload, enhance patient access, and improve overall practice efficiency.
But Medicare reimburses only 85% of the physician fee schedule for services provided by NPPs. The right way is to use incident-to billing. This billing strategy enables you to capture full reimbursement for NPP services.
Mastering incident-to-billing opens opportunities to maximize productivity and significantly boost your practice’s revenue. Let’s break down the rules to ensure compliance and maximize reimbursement when billing "incident-to."
Incident-to billing is a Medicare reimbursement provision that allows non-physician practitioners (NPPs) to bill for services under a supervising physician’s National Provider Identifier (NPI).
A non-physician practitioner (NPP) can be a Nurse Practitioner (NP), Certified Nurse-Midwife (CNM), Clinical Nurse Specialist (CNS), or Physician Assistant (PA). When billed correctly, incident-to services are reimbursed at 100% of the Medicare Physician Fee Schedule instead of the standard 85% reimbursement rate for NPPs.
Medical billing can feel like a maze, complex, confusing, and full of potential pitfalls. Even minor errors in claim submission can result in denials, delayed payments, or audits.
Every medical practice wants to maximize reimbursement for its services. Yet, you may hesitate to take full advantage of incident-to billing due to concerns about compliance, documentation errors, or the fear of denials. Unfortunately, you're leaving money on the table.
Incident-to billing doesn’t have to be complicated. To help you get it right, here are eight rules you must follow when billing incident-to.
Incident-to billing is exclusive to Medicare. It applies only to professional services billed to Medicare, excluding services with their own benefit categories, such as diagnostic tests and vaccines (pneumococcal, influenza, and hepatitis B).
You can bill a service as incident-to only in a physician’s office or clinic where the supervising physician is physically present. It cannot be used in hospitals, skilled nursing facilities (SNFs), or home health settings.
Incident-to billing only applies after the patient's first visit, i.e., once the physician has initiated a patient's care and established a treatment plan. This means an NPP cannot bill the patient’s first visit as incident-to.
After the physician has established the diagnosis and treatment plan, an NPP can provide follow-up services under incident-to billing as long as the care is aligned with the initial treatment plan.
For example, suppose a physician evaluates a patient and prescribes medication for diabetes management. At a follow-up visit, the NPP checks the patient’s blood sugar levels, monitors medication adherence, and provides guidance that follows the physician’s original treatment plan. This visit qualifies for incident-to billing since the treatment plan remains unchanged and the physician is on-site for supervision.
If a patient presents with a new medical condition (or if it's a new patient), the physician must first evaluate and establish a treatment plan before an NPP can bill under the incident-to. If an NPP independently assesses and treats a new condition, the service is not eligible for incident-to billing.
For example, suppose a patient initially visits the clinic for hypertension, and the physician sets a treatment plan. On a follow-up visit, the patient mentions new joint pain. If the NPP evaluates and treats the joint pain without the physician’s involvement, the visit cannot be billed as incident-to; it must be billed under the NPP’s NPI.
The supervising physician and the NPP must be enrolled and credentialed with Medicare to bill for services under the incident-to. Without proper enrollment, incident-to billing is not permitted.
The NPP providing incident-to services must be an employee of the billing physician (if a sole practitioner) or the group practice. For example, if a physician shares office space with another independent doctor but does not employ the PA working under the other doctor, incident-to billing is not permitted. Since the PA is not under the billing physician’s supervision or employment, the service does not meet incident-to requirements.
CMS mandates that the physician provide direct supervision to bill under the incident-to rule. While the physician need not be in the same room during consultation, they must be physically present in the office suite and immediately available to assist if necessary.
Incident-to billing is a powerful way to optimize reimbursement for NPP services. However, you must follow the incident-to guidelines to stay compliant and maximize revenue. Even small mistakes can lead to claim denials, delayed payments, or audits. To make the most of incident-to billing, implement these key steps:
At Glenwood Systems, we make incident-to billing simple and stress-free with expert guidance, automated compliance checks, and streamlined billing solutions. Our advanced practice management tools ensure you submit clean claims, capture maximum reimbursement, and stay compliant.
Focus on delivering quality patient care, and let us handle the complexities of billing and compliance. Partner with us to optimize reimbursement, reduce compliance risks, and thrive. Let’s connect today!
Schedule a Free Consultation!
