Medicare Billing Rules

“Incident to” Services Medicare Billing Rules:

April 2007 – Meditec

“Incident-to” services allow certain practitioners, physician assistants and nurses to bill for services of “non-professional auxiliary personnel,” as if the provider performed the service her/himself. The rules are a little tricky and must be followed to avoid false claims issues.

Upon the review of the descriptors, the rules seem straightforward. The service/supply must be:

1. Integral but incidental to the physician’s service.
2. Service is commonly done without a charge or is included in the physician billing.
3. Service furnished in the physician office or clinic.
4. Service must be under direct supervision.

The interpretation by CMS requires a physician to have provided initial (or subsequent) services to the patient, and the incident-to services are of course incidental to the provider’s care. That doesn’t mean the provider’s service must immediately precede every incident-to service. Rather, it means there has to have been a provider service to initiate a course of treatment during which the incident to services are performed. Obviously, an “incident-to” service could not be provided to a new patient. Once the patient is “established,” it could.

CMS also interprets that services must be rendered subsequently to show the provider’s active participation in the management of the treatment course. No rules for specific frequency are suggested, though CMS does say that some Medicare local carriers may have adopted frequency requirements. So it is important to check with your area Medicare carrier to discover such facts.

Remember too that the incident-to rules are only for services rendered in an office setting (nonstitutional). If performed in a patient’s home or institution (other than a hospital or skilled nursing facility) services may be covered only if under the direct supervision of the billing physician.

“Direct supervision,” means that the physician must be in the office suite where the services are performed. In a nonoffice setting, direct supervision requires the physician be in the immediate presence of the auxiliary personnel while the services are performed. The manual provisions clarify that for hospital and skilled nursing patients who are under Medicare covered stays, there is no Medicare Part B coverage for incident to services.