Incident-to billing for advanced practice providers (nurse practitioners, physician assistants, clinical nurse practitioners, nurse midwives, etc.) has been available to limited license practitioners since 1998. And the rules for what is required to bill incident-to are clearly defined by the Centers for Medicare & Medicaid Services (CMS). Yet, this privilege, which enables a limited license practitioner to bill under a physician and be paid at the full physician fee schedule (rather than 85 percent), is continually abused and billed incorrectly. As a result, CMS is considering eliminating the ability to bill for APPs via incident-to provisions.

Let’s look at what is required to bill under incident-to provisions under the current Medicare regulations. Keep in mind that these rules apply to Part B patients only. If a patient has Medicaid, Medicare Advantage, or is not a Medicare patient, the rules for that patient’s insurance company must be determined before billing incident-to. Do not assume the patient’s payer follows Medicare’s rules.

Follow the Rules

To bill incident-to, the following conditions must exist:

• The service is provided in the office. Incident-to services may not be provided in a facility, which includes, but is not limited to, outpatient clinic, emergency department, inpatient, and skilled nursing facility.
• The APP is following a plan of care established by the patient’s physician. This means that if the plan of care is changed (for example, changing the patient’s prescriptions), the plan of care is no longer being followed, and the visit no longer applies for incident-to billing.
• The APP is under direct supervision of a physician. This means there is a physician in the office suite; it does not mean there is a physician on a different floor in the same building, or in the hospital attached to the office building, or available by phone. The physician must be in the same office suite as the APP when the incident-to services are provided. Also:
  • The supervising physician does not have to be the patient’s physician who established the plan of care.
  • A best practice would be for the APP to document in the chart: “Ðr. Smith in the office supervising today,” to establish the presence of the supervising physician.
  • The incident-to service is billed under the supervising physician, not necessarily the patient’s physician who developed the plan of care.

Another fatal error is billing the incident-to service under the patient’s physician and not under the supervising physician.

Never Assume

Do not assume your Medicaid payer follows Medicare Part B just because Medicaid is part of CMS. Some states’ Medicaid programs, such as Kansas’ program, do not allow incident-to billing of APPs. Kansas pays 75 percent of their fee schedule when an APP delivers a service. Billing an APP incident-to in Kansas and any states’ Medicaid program that has similar rules is considered fraud.

Risky Business

As you can see, there are many ways in which visits can violate the incident-to rules. Without an audit, your Medicare carrier won’t know that the rules have been violated since a claim for an incident-to service looks exactly like a claim from the supervising provider. Audits are triggered when CMS sees a significant number of services for a single physician because both the provider and the APP are billing under the physician’s National Provider Identifier (NPI).

There is no modifier or other method to indicate that a claim is coming from an incident-to provider. Some private payers, such as UnitedHealthcare, have created their own modifier so that they can track incident-to usage. UnitedHealthcare Policy Number 2019R5009B provides, The SA modifier is a payable modifier and should be used by the supervising physician on behalf of the Advanced Practice Health Care Providers.

Because it is difficult to manage the correct billing of incident-to services, some practices have made the decision to accept the 15 percent loss for the few true incident-to services and always bill APP services under the APP’s own NPI. That way, they do not have to worry about all the billing requirements.

Stay tuned here to see what is finally decided by CMS.