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Posts Tagged ‘Physician Billing’

“Incident to” Billing Rules Clarified by CMS for 2016

Thursday, September 1st, 2016

Recent Changes to Medicare “Incident To” Billing Rules

incident to billing rules supervision requirementMedicare permits a physician to bill for certain services that are furnished by a nurse practitioner or other auxiliary personnel under what is referred to as the “incident to” billing rules.  The “incident to” rules permit services or supplies furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness to be reimbursed at 100% of the physician fee schedule, even if the service is not directly furnished by the billing physician.

A significant requirement to permit the services of physician extenders to be billed as “incident to” services requires direct personal supervision by the physician. The supervising physician does not necessarily need to be present in the same room where the procedure is being performed.  The “direct supervision” standard requires the supervising physician to be “physically present in the office suite and immediately available to furnish assistance and direction” during the time when the  auxiliary personnel is providing the service.

The 2016 Medicare physician payment rule provided some clarification on how the direct  supervision requirement under the “incident to” billing rules operates.  The new rule clarifies that the physician who directly supervises the applicable auxiliary personnel is the only party that can bill the service of the auxiliary personnel as “incident to” his or her service.  CMS considers this to be a clarification of its longstanding policy, but many providers will see this as a new restriction on the application of the “incident to” rules.

To understand the significance of this “clarification,” it is useful to note that more than one physician is often involved in the care of a patient.  It is not uncommon for one physician to visit the patient and order a test or procedure that is supervised by another physician.  Prior to this “clarification,” the physician that originally ordered the service might have billed the service as “incident to” even though another physician actually supervised the performance of the service.  The revised regulatory language clarified that this is not permitted and that only the physician that is actually present in the office suite and supervises the service can bill for the service as “incident to” their service.  When making a claim for services billed “incident to” a physician’s services, the billing number of the physician that actually supervises the performance of the service must be used rather than that of the ordering physician.

CMS clarifies the reasoning behind this rule as follows: “[B]illing practitioners should have a personal role in, and responsibility for, furnishing services for which they are billing and receiving payment as an incident to their own professional service.”

In view of this regulatory clarification, providers may wish to reexamine their billing process and procedures to clarify the correct billing for “incident to” services.  Staff should also be trained on the proper supervision of services that are billed under the “incident to” rules.

Incident To Billing – Physician Office Setting

Tuesday, February 7th, 2012

Billing of “Incident To” Services In Physician’s Office

Physician offices will generally bill for certain services performed by non-physician personnel as “incident to” the services of a physician.  “Incident to” services generally means services or supplies that are furnished as an integral, although incidental, part of the personal professional services of the physician.

The determination of whether a service is provided “incident to” a physician’s services can also have physician compensation implications.  The Stark law permits a group practice physician to be compensate based on personal production and “incident to” services.  Services that cannot be billed “incident to, such as diagnostic imaging services, cannot be credited directly to the physician when determining compensation within the group, a number of requirements must be met in order to bill a service as “incident to” the physician’s service performed in a physician’s office (as opposed to an outpatient department of a hospital).  The “incident to” billing requirements are summarized by the Center for Medicare and Medicaid Services in Chapter 15 of the Medicare Benefit Policy Manual.

Services and supplies commonly furnished in physicians’ offices are covered under the incident to provision. Where supplies are clearly of a type a physician is not expected to have on hand in his/her office or where services are of a type not considered medically appropriate to provide in the office setting, they would not be covered under the incident to provision.  Supplies usually furnished by the physician in the course of performing his/her services, e.g. bandages, and oxygen,  are also covered.

To be covered supplies, including drugs and biological, must represent an expense to the physician or legal entity billing fir he services or supplies. For example, where a patient purchases a drug and the physician administers it, the cost of the drug is not covered.  However, the administration of the drug, regardless of the source, is a service that represents an expense to the physician. Therefore, administration of the drug is payable if the drug would have been covered if the physician purchased it.

The physician must directly supervise the personnel performing the applicable service.  Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide.  However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.  The availability of the physician by telephone and the presence of the physician somewhere in the institution does not constitute direct supervision.  The physical presence of the physician is required in order to bill the service “incident to” the physician’s service.  In a group practice setting, other group members can supervise services that are ordered or directed by another physician member of the group.  However, a physician group members must be available in the office suite in order to bill the service on an “incident to” basis.  If there are no physicians in the office at the time that the service is rendered to a patient, the service cannot be billed. Even if the provider has the ability to provide the applicable service independently, physician supervision must be present if the service is billed “incident to” the service of a physician.  There must also be a primary physician professional service furnished to initiate a course of treatment.  The physician must provide the initial service and the non physician practitioner’s service must be related to the initial service in order to be billed “incident to.”

 The personnel providing the services must have  legal relationship to the entity that is billing the service as “incident to” the service of the physician.  In most cases this will not raise a problem because an employee of the practice will be billing the services.  However, this issue can raise a problem in cases where an outside provider supplies personnel to operate the technical component of medical equipment.  Inappropriate billings for “incident to” services present a significant compliance area for physician practices.  Policies should be put in place to direct staff on the appropriate rules to assure that a service is correctly billed.

John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
500 First Street, Suite 8000
P.O. Box 8050
Wausau, WI 54402-8050

Tel 715.845.4336
Fax 715.845.2718

Ruder Ware is a member of Meritas Law Firms Worldwide

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