'Incident-to' Billing Explained: Who Uses It, When, and Why?

Carolyn Buppert, MSN, JD

Disclosures

September 30, 2016

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Question

"What are the implications of billing 'incident-to' for services provided by NPs? Specifically, can a practice bill a commercial payer under a physician's name for services performed by an NP? Are 'incident-to' rules just applicable to Medicare? How about Medicaid?"

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

A nurse practitioner (NP) asks, "What are the implications of billing 'incident-to' for services provided by NPs? Specifically, can a practice bill a commercial payer under a physician's name for services performed by an NP? Are 'incident-to' rules just applicable to Medicare? How about Medicaid?"

Medicare's incident-to billing rules (also called billing for "shared visits") allow a physician, advanced practice nurse (APN), or physician assistant (PA) to bill under his or her national provider number (NPI), for evaluation and management services provided by someone else, under certain specific conditions. The conditions for billing incident-to for an office visit are:

  • The service is provided in an office;

  • Both the physician and NP or PA are employed by the same entity;

  • The provider under whom the service is billed is in the office suite when the service is provided;

  • The provider under whose name the service is billed has provided the "initial service" for the episode of illness or injury; and

  • The provider under whose name the service is billed remains involved in the care of the patient.

Medicare's rules on incident-to billing are found in the Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.B, available here.

Why Use Incident-to Billing?

The reason for billing incident-to is increased fee reimbursement. Medicare pays 85% of the physician fee schedule rate when an APN or PA bills an evaluation and management service under his or her own name. Incident-to billing allows a practice to receive 100% of the physician fee schedule rate when the service is provided by a PA or APN, billed under a physician's name, and the incident-to rules are followed.

Incident-to billing also allows a PA or APN to bill for a service provided by another clinician at the practice. For example, an NP sees a new patient, documents that the patient's blood pressure is high, and asks the patient to return to the office in 3 days for a recheck of the blood pressure. The initial visit is billed under the NP's name. On the return visit, a registered nurse (RN) employed by the practice takes and records the patient's blood pressure, and it is normal. The NP is in the suite but does not see the patient that day. The patient's visit with the RN may be billed as a Current Procedural Terminology (CPT) 99211 visit under the name of the NP.

Medicare also has rules for billing shared visits to patients who are admitted to a hospital, who are seen at a hospital outpatient clinic, or who are seen in an emergency department. In those settings, the rules are:

  • Both the advanced practice provider and physician are members of the same group practice; and

  • Both providers have provided and documented a face-to-face visit with the patient that day.

Under the rules for shared visits, the work performed by the advanced practice provider and the work done by the physician may be combined and billed, under the physician's name, using the appropriate CPT code for the combined work.

No form of incident-to billing exists for patients seen in their rooms at a nursing home.

Do Other Insurers Accept Incident-to Billing?

Medicare's rules on shared visits and incident-to billing are Medicare's, and one can't assume that Medicaid and commercial payers have adopted those rules. It is necessary for someone at a practice to ask the relevant state's Medicaid program and each commercial payer whether all services must be billed under the name of the rendering provider, or whether any other manner of billing is acceptable. It is useful to keep a spreadsheet detailing each payer's rules.

 
Individuals....who have not followed payer rules have been prosecuted for billing fraud.
 

It is important for practices to follow Medicare's rules and the rules of other payers closely. Individuals who have billed under the name of a provider who was not the rendering provider and who have not followed payer rules have been prosecuted for billing fraud. At minimum, groups that failed to follow the rules have been forced to repay the difference between 85% and 100% of the physician fee schedule rate for all visits billed in error.

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