by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Just about any large clinic you visit will have non-physician practitioners, or NPPs. These will include physician assistants, nurse practitioners, and clinical nurses for example. Practices and clinics can bill under the NPPs if they are credentialed with the payer, but the reimbursement is only 85% of the fee schedule. There is one rule that allows the NPP to treat and bill with 100% reimbursement, called "incident to", under Medicare rules. The billing requirements are in the Medicare Benefit Policy Manual, Chapter 15, Section 60. Read this section if you are doing any "incident to" services.
One of the most important aspects of "incident to" services is the services must be performed under the direct supervision of the physician. This does not mean the physician must be present in the exam room. However, the physician must be present in the office and immediately available to provide assistance and direction throughout the time the service is being performed. The physician is also not agreeing with the PA's treatment, but is supervising the PA. Therefore, agreeing with the PA's signed notes or stating the physician was present does not meet the criteria to be covered as "incident to".
In order to be covered as "incident to" the physician’s service, the following criteria must be met:
- services must be an integral, although incidental, part of the physician’s professional service,
- commonly rendered without charge or included in the physician’s bill,
- of a type that is commonly furnished in physician’s offices or clinics, and
- furnished by the physician or by auxiliary personnel under the physician’s direct supervision
OPPS and CAH Outpatient
According to "incident to" clarification for OPPS and CAH Outpatient (A55214), "incident to" does not pertain to the inpatient setting, such as a hospital or skilled nursing. It is only applicable in the outpatient hospital setting.
Medicare may reimburse the costs of services provided either:
1. delivered personally by eligible practitioners, e.g., MD, NP, PA; or
2. delivered by hospital personnel working “incident to” the eligible practitioner’s care.
When hospital personnel provides services, the following payment requirements must be met. Services delivered incident to the services of an eligible practitioner must:
- Be an integral although incidental part of a physician’s/non-physician practitioner’s (NPP’s) professional service(s) and, hence, must always occur after an initial patient care service is provided by an eligible practitioner;
- Be delivered in accordance with a valid and signed order, i.e., written by “a practitioner who is authorized to write orders by hospital policy and in accordance with state law…” 42 CFR§482.12(c);
Be delivered under the supervision of a physician who is an employee or has another contractual relationship with the hospital and is immediately available to provide assistance to the personnel delivering the service;
"Immediately available" in the outpatient hospital setting means that the physician must be available in the same time-frame as the personnel designated to manage cardiac arrests (codes) in the hospital.
The supervisor need not be in the same department as the ordering physician/NPP or in the same department in which the services are rendered but must be on the physical premises where and when the patient receives services.
The physician/NPP that provides the oversight may not bill for the services of hospital employees. Only the hospital may bill for the services of hospital employees.
All service providers must work in accordance with their skills, license, and/or other hospital and other Medicare requirements.