Incident to - What does that mean?

I have seen a lot of misinformation lately regarding Incident to. Let me break it down for you.

Navigating Medicare "Incident To" Guidelines: What Providers Need to Know

Understanding Medicare's "Incident To" guidelines is essential for healthcare providers to ensure proper billing and compliance. These guidelines allow certain services provided by non-physician practitioners (NPPs) to be billed under a physician's National Provider Identifier (NPI), but there are specific criteria that must be met.

Non-physician practitioners (NPPs) could include Physician Assistants (PAs), Nurse Practitioners (NPs), Clinical nurse specialists (CNSs), Certified nurse midwives (CNMs) and Certified registered nurse anesthetists (CRNAs).

Key Requirements:

1. Direct Supervision: A physician must be physically present in the office suite and immediately available to assist and direct throughout the performance of the service. This physician does not need to be the physician that created the plan of care. The physician in the office suite, would be the billing physician.

2. Integral Part of Service: The services provided by the NPP must be an integral part of the patient’s normal course of treatment during a visit initiated by the physician.

3. Established Patient: The patient must be an established patient, and the services must be related to a treatment plan created by the physician.

4. Employment Status: The NPP must be an employee, leased employee, or independent contractor of the physician or the same entity employing the physician.

Practical Tips:

· Documentation: Ensure thorough documentation, noting the physician’s initial involvement, which is documenting the plan of care and routine.

· Training and Protocols: Train staff on the specifics of "Incident To" services and establish clear protocols to maintain compliance.

· Regular Audits: Conduct regular audits to ensure that services billed as "Incident To" meet all Medicare requirements.

Adhering to these guidelines not only ensures compliance but also maximizes reimbursement potential while maintaining high standards of patient care. For more detailed information, refer to the official Medicare guidelines or consult one of our experts at TMPS.

Keeping this information at the forefront will help ensure that your practice remains compliant with Medicare’s "Incident To" billing requirements, ultimately protecting your practice from potential audits and penalties.

Not all Commercial Insurances follow Medicare “Incident To” guidelines. Please review those individual Payer Policies for direction.

Need help determining the ins and outs of Incident to. Schedule a consultation with us at Triumph Medical Practice Solutions. Admin@triumphmps.com or 214-305-8805