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Specific Medicare Requirements for Billing Incident-to” Services”

In many offices, physician assistants (PA) and nurse practitioners (NP) perform the incident-to services under the supervision of a physician.  When it comes to billing for services provided by any of these staff groups, there are different physician-fee schedules for Medicare patient billing.

Services will be billed under the physician’s National Provider Identifier (NPI) if the physician is supervising.  These are paid at 100% of the Medicare physician fee schedule.  If the PA or NP supervises the services, then it is billed under their NPI and reimbursed at 85% of the physician fee scheduled.  Because incident-to services are so commonly performed by PA and NP staff, billing had naturally been filed under the physician’s NPI.  However, with billing requirements becoming more specific, it is important that medical staff understand the new Medicare definitions for incident to services that will be billed under the supervising physician’s NPI in order to avoid potential fraud, abuse allegations, and audits.

What now qualifies as “incident-to” services?

Common incident-to services include taking vital signs, dressing and redressing wounds, removing sutures, and administering injections. In order to bill under the physician’s NPI, the following specific requirements must be met. These requirements are: the PA/NP performing the service must be directly under the supervision of, as well as an employee of, the physician; this physician must be involved in the patient’s treatment course; and the physician must be physically present in the office suite when the patient is being evaluated by the PA or NP.

Another requirement is that the patient must be an established patient with an established problem who met with the physician for the initial encounter and service.  This initial encounter cannot qualify as the physician coming in to say hello during their first visit. It must be initiated and completed by the physician. PAs and NPs must file services under their own NPI if they treat an established patient for a new problem (for example, if during a routine psoriasis follow up the PA notices and biopsies a suspicious lesion for basal cell carcinoma). Physicians must also remain actively involved in the patient’s subsequent treatment course.

When documenting services, it should be clear who performed the services and confirmed that the physician was in the office suite. The physician’s dated signature is helpful. 

PAs and NPs can find precise information about billing and exact definitions of supervisor requirements for their state in the Medicare Benefit Policy Manual. 


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