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“Incident to” Services

This article has been specially designed for our providers who perform services “Incident to” the services of a physician/NPP.

The “Incident to” Provision of Medicare

“Incident to” services are defined as those services that are furnished incident to a physician’s professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home. Under Medicare Part B, “incident to” provisions apply in an office setting only. There is no incident to billing in a facility under Part B.

“Incident to “services are billed as Part B services to your MAC as if you personally provided them, and are paid under the Medicare Physician Fee Schedule. Therefore, “Incident to” services are submitted under the physician’s NPI but are actually performed by someone else.

To qualify as “incident to,” services must be part of the patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. You do not have to be physically present in the patient’s treatment room while these services are provided, but you must provide direct supervision, that is, you must be present in the office suite to render assistance, if necessary. The patient record should document the essential requirements for incident to service.

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 60, 60.1, and 60.2 discusses the incident to requirements.

  • Section 60:
    • To be covered incident to the services of a physician or other practitioner, services and supplies must be:
    • An integral, although incidental, part of the physician's professional service (see 60.1)
    • Commonly rendered without charge or included in the physician's bill (see 60.1.A)
    • Of a type that are commonly furnished in physician's offices or clinic (see 60.1.A)
    • Furnished by the physician or by auxiliary personnel under the physician's direct supervision (see 60.1.B)
  • Section 60.2:
    • "… there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician's continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary."

The following paragraphs discuss the various care settings, which are important to note because the processes for billing vary somewhat depending on the care site.

Your Office

In your office, qualifying “incident to” services must be provided by a caregiver whom you directly supervise, and who represents a direct financial expense to you (such as a “W-2” or leased employee, or an independent contractor).

You do not have to be physically present in the treatment room while the service is being provided, but you must be present in the immediate office suite to render assistance if needed. If you are a solo practitioner, you must directly supervise the care. If you are in a group, any physician member of the group may be present in the office to supervise.

Hospital or SNF

For inpatient or outpatient hospital services and services to residents in a Part A covered stay in a SNF the unbundling provision (1862 (a)(14) provides that payment for all services are made to the hospital or SNF by a Medicare intermediary (except for certain professional services personally performed by physicians and other allied health professionals). Therefore, incident to services are not separately billable to the carrier or payable under the physician fee schedule.

In Patients’ Homes

In general, you must be present in the patient’s home for the service to qualify as an “incident to” service. There are some exceptions to this direct supervision requirement that apply to homebound patients in medically underserved areas where there are no available home health services only for certain limited services found in CMS IOM Publication100-02, Medicare Benefit Policy Manual, Chapter 15 Section 60.4 (B). In this instance, you need not be physically present in the home when the service is performed, although general supervision of the service is required.  

You must order the services, maintain contact with the nurse or other employee, and retain professional responsibility for the service. All other incident to requirements must be met. A second exception applies when the service at home is an individual or intermittent service performed by personnel meeting pertinent state requirements (e.g., nurse, technician, or physician extender), and is an integral part of the physician’s services to the patient.

Ambulance Service

Neither ambulance services nor EMT services performed under your telephone supervision are billable as “incident to” services.

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