Under what circumstances may a physician bill in his/her own name and provider number for a service rendered by another professional as an “incident to” service?
“Incident to” services are services performed by auxiliary personnel supervised by a physician but are billed on the claim as if the service has been provided as part of the physician’s own services. For instance, a physician might treat a patient and then hand over the care to her nurse practitioner or physician assistant. “Incident to” billing has been the subject of increased scrutiny and audits, as the difference in reimbursement can be 15% greater, so it is critical that the pre-requisites to such billing are properly met – and documented.
Of primary concern is that the service performed by such ancillary personnel be an integral, although incidental part of a physician practice’s professional services. In essence, the physician must be actually and directly involved in the patient’s care, which must be properly evidenced (i.e., appropriately documented, in medical record notations, care plans, and otherwise) to justify payment and withstand an audit.
The following briefly summarizes these requirements:
A. Preceded by a related physician service. The “incident to” service must be preceded by a related physician service, which physician then authorizes the “incident to” service (e.g., therapy). This is usually accomplished through the conduct of an initial consultation/evaluation or course of care with the patient by a physician who identifies the problem which the “incident to” service is meant to treat. The incident to service must be related to an initial covered service and be both essential and connected to the physician’s delivery of care for the specific problem identified.
If the patient presents with an initial problem – or later, during the course of ancillary treatment, a new problem – in both cases the physician must first see the patient and provide a valid billable service (i.e., consultation) before the services by the ancillary professionals are considered “incident to”. The initial service ordered (e.g., therapy) cannot attend to a new problem, symptom or different condition than that initially identified or treated by the physician.
The authorization for the ancillary service may be part of a care plan or other part of the medical record, and may further be evidenced by a written order.
B. Furnished under the care of a physician during the course of diagnosis and treatment of an illness or injury. The authorizing physician must personally see the patient periodically and sufficiently often as is clinically appropriate in order to assess the course of treatment using the ancillary professional and the patient’s progress. As necessary, the authorizing physician must change the treatment regimen to ensure that the underlying problem he/she originally identified or treated is being benefited by the “incident to” ancillary service. A face-to-face interaction with the patient is critical. In other words, the authorizing physician must take an active role in the management/oversight of the ancillary service. The physician should further document review of the patient’s records of treatment (e.g., therapy records).
C. Furnished by qualified personnel under the direct supervision of a physician. The supervising physician is the physician whose name the claim is actually submitted under as an “incident to” service. The authorizing physician need not necessarily be the same physician who serves as the supervising physician (provided they both are in the same group practice).
To satisfy the billing requirements, the supervising physician must be present in the office suite and immediately available to provide direction and assistance if necessary at the time the ancillary “incident to” service is performed. The physician need not be present in the same room, however.
The supervising physician is responsible for the appropriate rendering of the service itself at the time it is performed, including that it is safe and effective and furnished in accordance with accepted standards of medical practice – rather than the management of the course of care overall. In other words, he must be available should input be needed or should something go wrong.
It should be noted that Medicare publications imply a preference for the authorizing physician to also serve as the supervising physician, unless he/she is not available in the office at the time the service is rendered.
