Don’t Let Incident-to Billing Rules Trip You

The recent audits recoveries and Medicare settlements are testimony that providers are still wary of “incident-to” rules. Not understanding the incident-to standards can be ruinous as it can result in fraudulent billing and law violations. To help you navigate the rules better, here is a primer on incident-to billing rules.

Physician and non physician practitioners work closely as a unit to provide physician services; the provided services can be billed under the physician’s provider number under the Medicare provision for “incident-to billing”. But, there are certain rules to be followed when billing services under the incident-to provision.

Take a look at the rules:

  • Services provided by the NPP and physician are integral part of the physician’s professional service.
  • Services are commonly rendered without charge or included in the physician’s bill.
  • Services are of a type commonly furnished in physician’s offices or clinics.
  • Services are provided under the physician’s supervision and are provided by either the physician or by an individual who is an employee or independent contractor of the physician. Although, direct supervision does not require the physician’s presence in the same room but the physician must be immediately available.
  • The physician must perform “the initial service and subsequent services of a frequency which reflect his or her active participation in the management of the course of treatment.”
  • The physician or other provider under whose name and number the bill is submitted must be the individual present in the office suite when the service is provided.

 Physician/Providers Clinic

A physician or provider clinic is a place where the incident-to billing may be considered. The physician needs to be present to perform medical service at all times the clinic is open. In case of non physician services, the services are provided under medical supervision. In departmentalized clinics, the direct physician/provider supervision may be the responsibility of several providers as opposed to an individual provider. In this case, medical management of all services provided in the clinic is assured. The physician ordering a particular service is not necessarily the physician who is supervising the service. Hence, services performed by auxiliary personnel and other aides are covered even though they are performed in another department of the clinic.

Latest Medicare audit recoveries indicate that providers still have difficulty navigating the “incident to” rules. In some cases, there may not be any alternative to billing a service as incident-to, or the other options will result in less reimbursements. Renowned speaker Wayne J Miller will be talking about the five critical components to qualify for incident-to billing in an audio session. He will talk about the key attributes of supervision and documentation requirements that must be met in order to avoid fraud and other violations.

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