Nurse Practitioners and Incident-to Billing: The Indirect Billing Method

William J. Mazzocco Jr.

Disclosures

March 20, 2000

In This Article

General Incident-to Guidelines

The problem for practices is that there are no industry-wide standards for incident-to billing. Medicare is very specific about its incident-to requirements, but other insurers are more vague. Some insurers clearly deny its use by inserting such phrases as "physician only" or "the physician may not delegate" in rules or contracts. Incident-to billing for Medicare requires 4 basic components. Medicare's basic rules are not universal but they are used by many other third-party insurers. Each practice should obtain and review the appropriate information on incident-to billing before attempting to use this method.

  1. All new patients and old patients with new problems must be seen by the physician to first establish a treatment plan. (A new patient is defined as one who has not been treated by the practice for 3 years.) All core components of the exam must be personally performed by the physician. (There are exceptions to this rule, so it is imperative that the practice obtain the appropriate guidelines and criteria from insurance carriers and retain them for further reference.)

  2. For subsequent visits, the patient may be seen by a NPP. The NPP does not need to be an advanced practice provider (eg, NP or PA) but may be an RN, a medical assistant, or even an LPN, if permitted by the individual insurer. These services are billed under the physician's billing number at 100% of the physician's fee schedule.

  3. During subsequent visits, a physician member of the practice must be physically present in the office suite while the nonphysician employee renders service to the patient. The office suite must be a well-defined, limited area. For instance, the entire hospital, nursing home, or medical office complex cannot be construed as the office.

  4. Incident-to billing cannot be used for hospital inpatient billing. The act that established Medicare divides reimbursement into Medicare Part A (reimburses the healthcare facility) and Medicare Part B (reimburses the medical provider). Delegation of duties and subsequent billing for those inpatient professional services are not permitted.

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