"Incident to" Billing

The Centers for Medicare and Medicaid Services ("CMS") issued clarification regarding supervision requirements when billing "incident to" effective January 1, 2016.  In this HotStone, we highlight the recent clarification and review the major concepts relating to "incident to" billing.

It is important to note that the term "incident to" is a Medicare concept that does not apply to inpatient or outpatient hospital based services, but only applies to non-hospital based, outpatient practices who bill with Place of Service ("POS") 11.

Physician Supervision Clarification

In its Final Rule, "Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016," (published November 11, 2015, effective January 1, 2016) Medicare made a clarification for all providers billing Part B services regarding supervision under "incident to."  Based on the number of inquiries SunStone received, this clarification appears to have led providers to evaluate their current staff complement in outpatient practices and identify areas of risk in the supervision of, and billing of services under "incident to."  A summary of Medicare's clarification includes: 

  • The physician (or other practitioner) directly supervising the auxiliary personnel need not be the same physician (or other practitioner) who is treating the patient more broadly; and
  • Only the physician (or other practitioner) who supervises the auxiliary personnel who provide "incident to" services may bill Medicare Part B for those "incident to" services.

We understand that this clarification could have an operational impact for providers who may have billed previously under a "Medical Director."  However, with Medicare's "clarification," these arrangements will have to be re-visited to ensure that the billing practitioner and the supervising practitioner are one and the same.

Billing Under "Incident to"

Given the supervision clarification by Medicare, what follows is a basic summary of "incident to" billing guidance.  As mentioned previously, this is applicable to Part B professional services rendered in a non-hospital based setting.

  • For services rendered under the "incident to" provision, the attending practitioner who orders the service must first evaluate the patient personally and must initiate a course of treatment.
  • The appropriately trained mid-level practitioners may then render follow-up services to the patient, incident to the billing/supervising provider's services, which would then be monitored and supervised by the billing/supervising provider.
  • The supervising practitioner can be, but does not have to be, the attending practitioner who first saw the patient and oversees the plan of care.
  • There must be continued active participation by the attending practitioner in the management of the course of the services, including documented review of the notes and brief direct contact with the patient to confirm the findings.

For more information please contact Vonda Moon at 717-676-6133 or Georgia Rackley at 717-574-1947; or via email at vondamoon@sunstoneconsulting.com and georgiarackley@sunstoneconsulting.com, respectively.