CMS has published a Proposed Rule to clarify how physicians are to bill for services furnished “incident to” the professional services of a physician.
When a medical practice bills Medicare “incident to” for NPP services (i.e. “non-physician practitioners” such as nurses or physician assistants), the bill is rendered by the physician using the physician’s NPI number. Incident to services billed by the physician are paid at 100 percent of the fee schedule amount even though the physician did not perform the services. When the same services are billed by the NPP, the services are paid at 85 percent of the fee schedule amount. Specific requirements must be met for physicians to bill Medicare for incident to services. The services must be:
- Furnished in a noninstitutional setting to noninstitutional patients.
- An integral, though incidental, part of the service of a physician in the course of diagnosis or treatment of an injury or illness (understood to mean a physician has seen the patient first and initiated a plan of care being carried out by the NPP).
- Furnished under direct supervision of a physician or other practitioner eligible to bill and directly receive Medicare payment (meaning the physician is present in the office suite).
- Furnished by a physician, a practitioner with an incident to benefit, or auxiliary personnel.
NPP services may be billed under the physician’s NPI number when the services are part of the patient’s normal course of treatment, during which a physician performed an initial service and remains actively involved in the treatment.
The current regulations have caused confusion. The regulations state that the “physician supervising the auxiliary personnel need not be the same physician upon whose professional service the incident to service is based.” My interpretation of this is that a physician other than the physician that initiated the plan of care may supervise the NPP in the provision of services and such services will qualify as “incident to” if all other requirements are met. What remains unclear is which physician should bill for the incident to services, the supervising physician or the physician that initiated the plan of care. The proposed rule attempts to clarify that the billing physician must be the physician that supervised the services and not the physician that initially saw the patient and instituted the plan of care.
Care must be taken to ensure the supervising physician’s NPI number is used. This can be a challenge in busy medical offices where the physicians are regularly in the OR or conducting rounds.