Getting Paid for Your Non-Physician Practitioner’s Services With Incident-To Billing

non-physician practitioners, how to bill medicare, medicare physician fee schedule, physician fee schedule, nurse practitioner conferences

As the number of physicians shrinks and the demand for healthcare expands, practices seek solutions to their patient care needs — and many have found it by hiring non-physician practitioners, or NPPs. Physician assistants (PAs) and nurse practitioners (NPs) fill the gaps caused by physician shortages in primary care. In fact, a recent Brandeis University study reported that Medicare saves money when a beneficiary’s primary care provider is a nurse practitioner, with costs of care ranging between 11 and 29 percent less than those for patients whose primary care provider was a physician.

Get the Scoop on the Ins and Outs of ‘Incident To’ Services

When NPPs are eligible for direct billing to Medicare and private payers, they can bill under their own provider numbers. Medicare reimburses NPPs at a rate of roughly 85 percent of what the Medicare physician fee schedule (MPFS) specifies for physicians. But if the patient services provided by the NPP meet a strict set of guidelines, they may be eligible for incident to billing under the physician’s provider number, reimbursable at 100 percent of the MPFS amount.

In incident to billing, an NPP provides care to a patient under the direct supervision of a physician. The service must be medically necessary and follow an initial physician service where a physician sets a plan of care for a patient. This is why a new patient visit would never be subject to incident to billing.

In a recent teleconference training session, Ellen Berra of WPS Medicare explained the key to incident to billing. For incident to billing to apply, “the physician has to have established the plan of care and have active participation in the patient’s ongoing care,” she said. She added that CMS guidelines do not spell out how frequently the physician needs to see the patient. “The guidelines don’t indicate that the physician has to see the patient every third or fourth time,” she said. Rather, she said, it should be clear when someone from outside the practice reviews the patient’s medical record that the physician is still the one in charge, and that the physician hasn’t turned the patient’s care over to the NPP.

‘Oh, By the Way …’

Berra added that those “Oh, by the way” situations can move a service out of incident to billing status in a flash. These are those cases where a patient comes in for diabetes or congestive heart failure followup, with the NPP providing care based on a plan created by the supervising physician. “But then the patient says, ‘Oh, by the way, I have this rash on my elbow, can you look at it?’” Berra said. That request moves the service out of incident to eligibility because the NPP is no longer working under the doctor’s care plan, she said. Once this happens, you must bill under the NPP’s provider number. “At this point, we get the question, ‘Can the NPP just go get the doctor to review the rash and have it be incident to?’ The answer is no,” Berra said.

Physician Must Be Within ‘Speaking Loudly Distance’

Berra also addressed the location question for incident to billing. Some practices incorrectly bill for incident to services, thinking that as long as the supervising physician is in the building when the NPP sees the patient, the rules are met. But not so, says Berra. You can only bill incident to services for an NPP when the supervising physician is physically in the office suite, “within ‘speaking loudly distance,’ which is how one of our medical directors puts it,” Berra said. “That means not shouting distance, not available by walkie-talkie or telephone, not on a different floor, but within that designated office space.” The reason for this? The regulations say that the physician has to be immediately available to take over the service should the need arise, Berra said.

You can listen to Berra’s audio conference here.

Got ‘Incident to’ Tips?

Berra’s explanations of the reasoning behind incident to billing rules really made sense to me. How about you? Got any tips to share? Let us know in the comment box below.

Subscribe to Medicare Compliance & Reimbursement for Expert Part B Tips!

Documentation requirements keep getting more stringent, compliance and reimbursement challenges tougher, and regulations more full of legalese. How do you squeeze all the deserved reimbursement you can out of your Medicare claims while staying compliant with regulations? Subscribe to Medicare Compliance & Reimbursement! Sign up for a free trial today!


Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

, , , ,

Leave a Reply