{"id":41123,"date":"2023-02-17T10:58:59","date_gmt":"2023-02-17T15:58:59","guid":{"rendered":"https:\/\/mtelehealth.com\/?p=41123"},"modified":"2023-02-17T10:58:59","modified_gmt":"2023-02-17T15:58:59","slug":"medicare-compliance-basics-incident-to-billing","status":"publish","type":"post","link":"https:\/\/drmiltie.com\/at-home-testing\/medicare-compliance-basics-incident-to-billing\/","title":{"rendered":"Medicare Compliance Basics: \u201cIncident to\u201d Billing"},"content":{"rendered":"\n\n\n

In this first article, we set forth the general \u201cincident to\u201d billing requirements, in order to set the groundwork for the series. Note that this article reviews requirements to bill \u201cincident to\u201d a physician\u2019s professional services in an office setting.<\/p>\n\n\n\n

What are Incident To Services?<\/h2>\n\n\n\n

Medicare Part B allows a physician (or certain other non-physician practitioners) to maximize their productivity by receiving reimbursement for certain services furnished by \u201cauxiliary personnel\u201d on an \u201cincident to\u201d basis.<\/p>\n\n\n\n

Note that the ability to utilize \u201cincident to\u201d billing is subject to various requirements and limitations. The \u201cincident to\u201d requirements are set forth in (sometimes contradictory or at least hard to reconcile) federal regulations<\/a>, Medicare billing policies, and subregulatory guidance issued by local Medical Administrative Contractors (MACs). Failure to comply with the \u201cincident to\u201d rules can lead to issues ranging from claims denials, overpayments, being placed on pre- and\/or post-payment review or even false claims liability (with a lookback or statute of limitations of up to ten years).<\/p>\n\n\n\n

Who Does This Apply To?<\/h2>\n\n\n\n

Physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, clinical psychologists, clinical social workers, physical therapists and occupational therapists, also known as Non-Physician Practitioners (NPPs) have their own Medicare coverage categories, and can bill and provide professional services independently, subject to state law. For example, NPPs may provide professional services without direct physician supervision (subject to state law) and bill directly for these services. Services performed and billed directly by NPPs are reimbursed at a lower rate (85% of the Physician Fee Schedule rate for those services when performed by physicians). However, when an NPP\u2019s services are provided as \u201cauxiliary personnel<\/strong>\u201d, they may be covered as \u201cincident to\u201d services, in which case the \u201cincident to\u201d requirements would apply. Services provided \u201cincident to\u201d a physician\u2019s professional services are reimbursed at 100% of the Physician Fee Schedule rate for the identified physician service.<\/p>\n\n\n\n

For purposes of the physician \u201cincident to\u201d regulations<\/a>, \u201cauxiliary personnel<\/strong>\u201d means any individual who is acting under the supervision of a physician (or other eligible practitioner), regardless of whether the individual is an employee, leased employee, or independent contractor of the physician (or other practitioner) or of the same entity that employs or contracts with the physician (or other practitioner), has not been excluded from the Medicare, Medicaid and all other federally funded health care programs by the Office of Inspector General or had his or her Medicare enrollment revoked, and meets any applicable requirements to provide \u201cincident to\u201d services, including licensure, imposed by the State in which the services are being furnished.<\/p>\n\n\n\n

In later articles, we will be addressing the conditions under which an NPP may provide services \u201cincident to\u201d another NPP.<\/p>\n\n\n\n

\u201cIncident To\u201d Requirements<\/h2>\n\n\n\n

\u201cIncident to\u201d a physician\u2019s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician\u2019s personal professional services in the course of diagnosis or treatment of an injury or illness. The services must relate to an existing<\/strong> course of treatment; the \u201cincident to\u201d rules do not apply to a new patient or when treating an existing patient for a new illness or injury.<\/p>\n\n\n\n

To be covered \u201cincident to\u201d the services of a physician, Chapter 15, Section 60 of the Medicare Benefit Policy Manual<\/a> (Manual) and the \u201cincident to\u201d regulations<\/a> set forth that the services and supplies must be:<\/p>\n\n\n\n