Incident To Services – Medicare

Medicare has specific rules for billing for nurse practitioners and physician assistants and other office staff incident to a physician services in an office.  This article includes:

• Description, explanation and codes for incident-to services
• Brief video overview
• Billing and coding rules
• Enrollment of non-physician practitioners (NPPs) for incident-to billing
• Incident-to and change to medications

See Everyday coding for additional information.

Definition of Incident-to services

Incident-to services are services provided in a non-facility setting to Medicare patients that are incident-to a physician’s or non-physician practitioner’s (NPP) treatment and plan of care.  Use these in place of service 11. There are other non-facility settings in which incident to services may be provided, but office is the most typical.

Explanation

Incident-to care is care provided incident-to the care provided by the physician. This means, that the patient must be seen by the physician at a prior visit, the physician develops the plan of care, and that the care provided is an integral part of the physician’s treatment plan. The physician must stay actively involved in the plan of care and be in the office when the service is provided.

Certain health care professionals, such as PA’s and NP’s can bill their services as incident-to the physician. That is, the service is billed under the physician’s provider number, as if the physician had provided the service. Other employees can bill incident to, but these visits are then limited to a 99211. A staff member may also bill incident to an NPP, such as for a BP check.

Incident-to services are paid at 100% of the physician fee schedule. Services billed under the NP/PA provider number are paid at 85% of the physician fee schedule. NPPs who see new patients, or see established patients with new problems must bill those services under their own provider number. These do not meet the criteria of incident-to services.

Webinar

Medicare incident to and shared services webinar

In this 60 minute on-demand webinar, Betsy discusses the rules and guidelines for coding incident to and shared services. Watch now.

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