Medical RAC Audits Reviewed by Statistician Frank Cohen Medical RAC Audits Reviewed by Statistician Frank Cohen

6 Tips For Complying With Incident-To Rules

You could improve your patient volume and give your physicians more flexibility by having your non-physician practitioners bill under Medicare’s “incident-to” guidelines. These rules, which some private insurers have also adopted, allow nurse practitioners, physician assistants, and physical and occupational therapists to bill for services under the name and identifier of supervising physicians.

Medicare reimburses physicians at the full fee schedule rate, but only reimburses non-physician providers at 85% of the fee schedule rate. By allowing non-physician providers to bill for outpatient office visits at the full rate, physicians are free to see new patients or more complex cases, or perform surgery.

Other common in-office procedures, such as wound debridement or drug injections, can also be performed by a non-physician and billed incident-to, provided they follow incident-to rules (see below).

Incident-to tips and rules

Below are the most important incident-to rules along with tips to comply with them.

  1. Outpatient only, and payer-specific. Incident-to rules only apply to services rendered in the outpatient or office setting. Medicare and some, but not all, private insurance companies allow incident-to billing. For example, Anthem has its own incident-to policy, mostly copied from CMS.
  2. Services must be part of an existing plan of care. This is the single most important and often confused requirement for incident-to services. A plan of care for the patient must have first been created by the physician, or else the patient cannot be seen under incident-to guidelines. This means that the more expansive and well-documented the plan of care, the better, because the non-physician will have more latitude to manage the patient. Example: If a patient is recovering from an arthroscopic repair of a torn meniscus, and the plan of care includes language that supports increasing dosage for pain management medication or altering the type of medication as needed, then the non-physician may make these changes and still bill the service under the physician. If the plan of care did not specify what to do when drug changes are needed, the non-physician could not make those alterations and still bill under the physician.
  3. No new patients. Because a plan of care created by a physician must exist for the non-physician to follow (and have his/her services to be “incidental” to), no new patients can be seen by a non-physician provider.
  4. No new problems or changes to plan of care. The same logic applies to new problems or an existing problem with an exacerbation that requires altering the plan of care. Whenever the plan needs to change, the physician must take over the visit in order for the visit to be billed under the physician’s identifier at the full fee schedule rate. Alternatively, the non-physician can assume responsibility for the visit and bill under his or her identifier at 85% of the fee schedule rate.
  5. Physician supervision required. A physician must be available in the office suite if needed by the non-physician provider for any reason. He or she doesn’t have to be in the exam room, but does need to be immediately physically available (i.e. not on lunch break or only available via phone). This supervising physician does not need to be the same physician who created the plan of care.
  6. Plan of care needs to be updated and physician must stay involved. The physician must stay involved in the care of patients who are seen incident-to, and is expected to update the plan of care as needed over time. The plan itself must be readily accessible in case a payer decides to request your documentation for an audit.

Are incident-to rules too strict?

If you are able to comply with the rules above, you can find that your practice can see more patients without losing any revenue. But the rules aren’t easy for many practices, and there’s still one problem that has nothing to do with Medicare’s rules: Patient experience. Many patients expect to see the physician and aren’t happy being seen by a non-physician provider whom they perceive, often unfairly, as being less capable than an MD in treating their problems. To navigate this issue, you can point out to patients that the non-physician provider can usually see them sooner than your physicians, who are seeing new patients or performing surgery.