Course updated: May 2016Copyright 2015 Cahaba Government Benefit Administrators, LLC

By the end of this course, you will be able to:• Define "Incident To"• Understand the requirements• Locate the policy in the CMS Internet Only Manual (IOM)• Describe the difference between locum tenens and reciprocal billing

Overview“Incident to” services are defined as those services that are furnished as an integral, although incidental part of the physician’s professional services in the course of diagnosis or treatment of an injury or illness. These services may be furnished in the physician’s office or in a patient’s home.

Please Note...

For purposes in this training course, physician means physician or other non-physician practitioner (i.e., Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Nurse Midwife and Clinical Psychologist) authorized by the Act to receive payment for services “incident to” his/her own services. These non-physician practitioners are subject to the same “incident to” requirements as the physician.

Overview• Examples of qualifying “incident to” services include cardiac rehabilitation, providing non-self-

administrable drugs and other biologicals, and supplies usually furnished by the physician in the course of performing his/her services, e.g., gauze, ointments, bandages and oxygen.

• Medicare will not apply “incident to” requirements to services having their own benefit category. Rather, these services should meet the requirements of their own benefit category. For example, diagnostic tests are covered under Section 1861(s)(3) of the Act and are subject to the physician supervision level coverage requirements. Depending on the particular test, the supervision requirement may be more or less stringent than that discussed within the “incident to” criteria.

Please Note... Pneumococcal, influenza and hepatitis B vaccines are covered under Section 1861(s)(1) of the Act

and need not also meet “incident to” requirements.

Requirements

• To qualify as “incident to”, services must be a part of the patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment.

• The physician does not have to be physically present in the patient’s treatment room while these services are provided, but must provide direct supervision; that is, the physician must be present in the office suite to render assistance, if necessary.

• The patient record should document the essential requirements for “incident to” service.

More specifically, the “incident to” service must be all of the following:

• An integral part of the patient’s treatment course

• Commonly rendered without charge or included in the physician’s bill

• Furnished under the physician’s direct supervision

• Of a type commonly furnished in a physician’s office or clinic (not in an

institutional setting)

• An expense to the physician

Requirements

Direct Supervision• Coverage of services and supplies "incident to" the physician is limited to situations in which

there is direct supervision of auxiliary personnel.

• Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee or independent contractor of the physician, or of the legal entity that employs or contracts with the physician. Likewise, the supervising physician may be an employee, leased employee or independent contractor of the legal entity billing and receiving payment for the services or supplies.

• The physician personally furnishing the services or supplies or supervising the auxiliary personnel furnishing the services or supplies must have a relationship with the legal entity billing and receiving payment for the services or supplies that satisfies the requirements for valid reassignment.

• When a physician supervises auxiliary personnel who assist him in rendering services to patients and includes the charges for their services in his own bill, the services of such personnel are considered “incident to” the physician’s service, if there is a physician’s service rendered, to which the services of such personnel are an incidental part and there is direct supervision by the physician.

• Direct supervision requires the physician to be present in the office suite & immediately available to provide assistance and direction throughout the time auxiliary personnel is performing services. It does not mean the physician must be present in the same room.

Services and supplies "incident to" a physician’s service in a physician directed clinic or group association are generally the same as those previously described.

A physician-directed clinic is one where:• A physician (or a number of physicians) is present to perform medical (rather

than administrative) services at all times the clinic is open.• Each patient is under the care of a clinic physician.• The non-physician services are under medical supervision.

Incident To Office/Clinic

• Qualifying “incident to” services must be provided by a caregiver whom the physician directly supervises and who represents a direct financial expense to the physician (such as a “W-2” or leased employee, or an independent contractor).

• The physician does not have to be physically present in the treatment room while the service is being provided, but must be present in the immediate office suite to render assistance if necessary.

• If the physician is a solo practitioner, he/she must directly supervise the care. If the physician is in a group, any physician member of the group may be present in the office to supervise.

Incident To Office/Clinic

• In institutions, including skilled nursing facilities (SNF), the physician’s office must be confined to a separate identifiable part of the facility and cannot be construed to extend throughout the entire facility. The physician’s staff may provide services “incident to” physician services in the office to outpatients, to patients who are not in a Medicare covered stay or in a Medicare certified part of a SNF.

• If the auxiliary personnel (or contractor) provides services outside of the physician’s office area, these services would not qualify as “incident to” unless the physician is physically present where the service is being provided (one exception to this is certain chemotherapy services).

Offices in Institutions

• For inpatient or outpatient hospital services, including emergency room, the unbundling provision in Section 1862 (a)(14) of the Act provides that payment for all services are made to the hospital by the Medicare Administrative Contractor (except for certain professional services personally performed by physicians and other allied health professionals).

• There is no Medicare Part B coverage of the services of physician-employed personnel as services incident to physicians’ services for hospital patients or SNF patients in a Medicare covered stay.

Hospital Settings Institutional Settings• Institutional Setting (e.g. nursing or

convalescent home).

• Physician supervision must be direct.

• The availability of the physician by telephone or the presence of the physician somewhere in the institution does not constitute direct supervision.

Neither ambulance services nor emergency medical technician (EMT) services performed under a physician's telephone supervision are billable as “incident to” services.

AmbulanceIn Patient’s HomeIn general, the physician must be present with auxiliary personnel in the patient’s home for the service to qualify as an “incident to” service. Without the physician’s direct personal supervision, the service performed by auxiliary personnel would not be covered by Medicare.

Example(s):• If a LPN went on a house call with the physician

and administered an injection, the service rendered by the LPN would be covered as “incident to” by Medicare.

• If the LPN went on a house call without the physician and administered the same injection, the service rendered by the LPN would not be covered since the physician was not present and providing direct supervision.

An exception to the direct personal supervision requirement applies to homebound patients in medically underserved areas when all of the following are met:• The area has only a few physicians in the area to provide services, which significantly reduces

the availability of certain medical services.• The physician must order the services and maintain contact with auxiliary personnel• The physician must retain professional responsibility for the service• All other incident to requirements must be met

Additional requirements:• The patient must be considered homebound• The service is an integral part of the physician’s service to the patient and is performed

under general physician supervision by employees of the physician or clinic; and,• Services are included in the physician’s bill and the physician (or clinic) has incurred an

expense.• The service cannot be furnished by a Home Health Agency• When these requirements are met, a listing of covered services may be reviewed in CMS’

Internet Only Manual (IOM), Pub. 100-02, Chapter 60, Section 60.4 (B). All services must be medically necessary.

In Patient’s Home

• Homebound is defined as individuals considered confined the home but are not necessarily bedridden. The condition of these patients should be such that there exists a normal inability to leave home and, as a result, leaving their home would require a considerable and taxing effort.

• Patients will be considered homebound if they have a condition due to an illness or injury which restricts the individual’s ability to leave their place of residence except with the use of special transportation, or the assistance of another person or if they have a condition which is such that leaving their home would further endanger the patient’s health or condition.

• Aged patients who do not often travel from their home because of feebleness and insecurity brought on by advanced age are not considered confined to their home. If the patient is not considered homebound, Medicare cannot pay for the “incident to” services.

In Patient’s Home

1: Must a supervising physician be physically present when flu shots, EKGs, laboratory tests or x-rays are performed in an office setting in order to be billed as “incident to” services?=These services have their own statutory benefit categories and are subject to the rules applicable to their specific category. They are not “incident to” services and the “incident to” rules do not apply.

2: Dr. Jones employed a Nurse Practitioner to make rounds for him/her at the nearby nursing home. Can Dr. Jones bill those services as “incident to”?=No, “incident to” services are not allowed in an institutional setting. If there was no face-to- face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the Nurse Practitioner’s PIN/NPI.

3: Can anti-coagulation monitoring be provided “incident to” a physician’s services in an office?=Yes, if the requirements are met, i.e., the services are part of a course of treatment during which the physician personally performs the initial service and is actively involved in the course of treatment, is physically present in the immediate office when services are rendered by the employee and the service represents an expense to the physician or other legal entity that bills for the service.

4: If the treating physician (Doctor X) refers a patient to an anti-coagulation monitoring clinic, can Doctor X bill these services “incident to”?=No, because the services are not being provided by an employee under supervision of Doctor X.

“Incident To” Scenarios

Billing “Incident To”

After May 23, 2007 the 1G Qualifier and the UPIN in item 17a was no longer required.

After that time, bill the physician name in 17 and the corresponding NPI in 17b

When a service is “incident to” the service of a physician, the name and the National Provider Identifier (NPI) of the physician who performs the initial service and orders the non-physician services must appear in items 17 and 17 b or equivalent electronic field.

• “Incident to” services are covered in an office setting if the requirements are met. Meaning, the services are part of a course of treatment during which the physician personally performs the initial service and is actively involved in the course of treatment, is physically present in the immediate office when services are rendered by the employee and the service represents an expense to the physician or other legal entity that bills for the service.

• Services outside of the office (institutional settings) by auxiliary personnel without direct personal supervision by the physician are not separately billable to the carrier or payable under the “incident to” provision.

• In general, the physician must be present with auxiliary personnel in the patient’s home for the service to qualify as an “incident to” service. Without the physician’s direct personal supervision, the service performed by auxiliary personnel would not be covered by Medicare. There are exceptions if the patient is considered homebound.

Quick Review

Services performed by these non-physician practitioners “incident to” a physician’s professional services include:

• Services ordinarily rendered by a physician’s office staff person (i.e. medical services such as checking blood pressures, administering injections and changing dressings).

• Services ordinarily performed by the physician such as minor surgery, setting casts or simple fractures, reading x-rays and other activities that involve evaluation or treatment of a patient’s condition.

• Nonetheless, in order for services of a non-physician practitioner to be covered as “incident to” the services of a physician, the services must meet all of the requirements for coverage specified the Medicare Benefit Policy Manual, Chapter 15, Section 60.

Services of Non-Physician Personnel Furnished “Incident To” Physicians’ Services

• A non-physician practitioner such as a physician assistant or a nurse practitioner may be licensed under state law to perform a specific medical procedure without physician supervision and have the service separately covered and paid for by Medicare as a physician’s assistant or nurse practitioner’s service. However, in order to have that same service covered as “incident to” the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physician’s plan of treatment.

• While this does not mean that each occasion of an incidental service performed by a non-physician practitioner must always be the occasion of a service actually rendered by the physician, it does mean that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment.

• There must also be subsequent services furnished by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment.

Services of Non-Physician Personnel Furnished “Incident To” Physicians’ Services

Payment under the “incident to” provision should not be confused with other unique billing situations, such as:• Shared/Split Evaluation and Management Visits• Reciprocal Billing• Locum Tenens Billings

During the next few slides, we will discuss each of these subjects.

Other Unique Billing Situations

• In the office setting when the physician performs the E&M service, the service must be reported to Medicare using the physician’s PIN/NPI. When the E&M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed “incident to” if the requirements for “incident to” are met and the patient is an established patient.

• If “incident to” requirements are not met for the shared/split E&M service, the service must be billed to Medicare under the non-physician practitioner’s PIN/NPI. The payment will be made at the appropriate physician fee schedule payment.

Split/Shared E&M Visits

When a hospital inpatient, hospital outpatient, emergency department, hospital observation or hospital discharge E&M is shared between a physician and an non-physician practitioner from the same practice and the physician provides any face-to-face portion of the E&M encounter with the patient, the services may be billed under either the physician’s or the non-physician practitioner’s PIN/NPI. If there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the non-physician practitioner’s PIN/NIP.

Example:If the non-physician practitioner sees a patient in the hospital (inpatient) in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the non-physician practitioner may report the service.

Please Note: A split/shared E&M visits cannot be reported in the Skilled Nursing Home (SNF) or Nursing Facility (NH) setting.

Split/Shared E&M Visits

• A patient’s regular physician may have reciprocal arrangements with one or more physicians to substitute for him or her on an occasional reciprocal basis (i.e., to cover for the regular physician, to be on call). This type of arrangement, which is common in a medical group, does not have to be in writing. Medicare will not pay for this type of arrangement for services beyond a continuous 60-day period.

• Although the substitute physician must be a Medicare provider, the services are billed under the regular physician’s UPIN/PIN/NPI. Modifier Q5 (service furnished by a substitute physician under a reciprocal billing arrangement) is entered after the appropriate procedure code in Item 24d of the CMS-1500 form or equivalent electronic field. Medicare will make payment to the regular physician as though he/she had performed the services.

Please note: The use of modifier Q5 does not apply to substitution arrangements among physicians in the same medical group where claims are submitted in the name of the group.

• As previously mentioned, Medicare will not pay for this type of service beyond a continuous 60-day period.

Reciprocal Billing

The regular physician goes on vacation on June 30 and returns to work on September 4. A substitute physician provides services to the Medicare Part B patients of the regular physician on July 2 and at various times thereafter, including August 30 and September 2. The continuous of covered visit services begins on July 2 and runs through September 2, which is a 63-day period. Since the September 2 services are furnished after the expiration of 60 days of the period, the regular physician is not entitled to bill and receive payment for them. The substitute physician must bill for these services in his/her own name. The regular physician may bill for services that the substitute physician provides on his/her behalf in the period July 2 through August 30.

Example of Reciprocal Billing

• When a patient’s regular physician is absent for reasons such as illness, pregnancy, vacation or continuing medical education, the regular physician may retain a substitute physician to take over his/her professional practice. The regular physician bills and receives payment for the substitute physician’s services as though the regular physician had performed the services. The substitute physician is generally called a “locum tenens” physician.

• A written agreement between the regular physician and the substitute physician must be in place. The regular physician generally pays the substitute physician on a per diem or similar fee-for-time basis, with the substitute physician having the status of an independent contractor rather than of an employee. “Locum tenens” physicians generally are not Medicare enrolled providers in the jurisdiction as the local Medicare Part B contractor.

• The services of the locum tenens physician are billed to the Medicare Administrative Contractor under the regular physician’s PIN/NPI. Modifier Q6 (service furnished by a locum tenens physician) is entered after the appropriate procedure code in Item 24d of the CM-1500 form or equivalent electronic field.

• Medicare will make payment to the regular physician as though he/she had performed the services. Medicare will not pay for services beyond a continuous 60-day period.

Locum Tenens

• When a hospital inpatient/outpatient or emergency department E&M (visit) is split/shared between a physician and an non-physician practitioner from the same practice and the physician provides any face-to- face portion of the E&M encounter with the patient, the services may be billed under either the physician’s or the non-physician practitioner’s PIN/NPI.

• A patient’s regular physician may have reciprocal arrangements with one or more physicians to substitute for him/her on an occasional reciprocal basis. This type of arrangement is common and does not have to be in writing. Medicare will not pay for services beyond a continuous 60-day period.

• A locum tenens arrangement is a written agreement between the regular physician and a substituting physician that allows the regular physician to bill and receive payment for the substitute physician’s services as though the regular physician had performed the services. Medicare will not pay for services beyond a continuous 60-day period.

Review

You may use the following CMS web site links for additional information related to the “incident to” provision, split/shared E&M visits, reciprocal billing, and locum tenens:MLN Matters (SE0441) – “Incident To” Serviceshttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/downloads/se0441.pdf

IOM – Pub. 100-02, Benefit Policy Manual Chapter 15, Sections 50-60 and 160-210https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

Education Materialhttps://www.cahabagba.com/cahaba-u/part_b/incident_to/html/index.htm

IOM – Pub. 100-03, National Coverage Determinations Manual Section 70.3https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf

IOM – Pub. 100-04, Claims Processing Manual Chapter 26, Section 10https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c26.pdf

IOM – Pub. 100-04, Claims Processing Manual Chapter 1, Sections 30.2.10 – 30.2.11https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf

IOM – Pub. 100-04, Claims Processing Manual Chapter 12, Section 30.6.1https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

Resources

Click the link below and complete the “Incident To” Training Post-test:

http://w3.mccg.org/iota/test-incident-to.asp

When the test is successfully completed, you will be prompted to enter information to record your

results.