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How Incident-To Billing Makes Clinics More Profitable

By: Nextech | October 31st, 2024

How Incident-To Billing Makes Clinics More Profitable Blog Feature

Busy medical practices often employ non-physician healthcare practitioners to ease the workload on physicians. Incident-to billing ensures Medicare doesn’t penalize practices for this practical solution.

The Association of American Medical Colleges estimates the U.S. will be short as many as 86,000 physicians by 2036. Many specialty practices have only one or two doctors on staff.

These practices are maintaining and even expanding their productivity with the help of non-physician providers. The U.S. Bureau of Labor Statistics projects the number of physician assistant jobs will grow by 28% between 2023 and 2033.

Nursing specialist roles, such as nurse anesthetists and nurse practitioners, are expected to grow even faster. The bureau projects the nursing specialist field will grow by 40% over the same time period.

Non-physician providers allow practices to deliver outstanding care to more patients day in and day out. However, clinics need to be careful how they bill for this care.

When non-physicians provide services covered by Medicare, the Centers for Medicare & Medicaid Services (CMS) reimburses the practice at a lower rate than if the same service was performed by a physician.

Incident-to billing allows practices to avoid this payment reduction without adding physicians to the staff headcount.

What Is Incident-To Billing?

Incident-to billing is a strictly regulated billing method in which care delivered by non-physician providers such as nurses and physician assistants is billed as though it was delivered by a physician.

If a non-physician provider performs the service under a doctor’s direct supervision and meets all the requirements of incident-to billing, the service can be reimbursed at the full physician rate.

When non-physician providers perform services covered by Medicare, the government reimburses the practice only 85% of the rate it pays a physician to provide the same service.

2024 Incident-To Billing Guidelines

A service must meet specific requirements to qualify for incident-to billing under Medicare. Private insurers that permit incident-to billing have their own, separate guidelines.

CMS Incident-To Billing Requirements

When deciding whether a service qualifies for incident-to billing, CMS considers factors including the location, the service, the treatment plan, and the patient’s relationship with the practice.

When a service meets all the requirements of incident-to billing, it can be billed under the supervising physician’s National Provider Identifier (NPI), as though the physician themselves performed the service.

Location

  • Services billed incident-to must be performed in a non-institutional setting like a clinic. They cannot be performed in a hospital or skilled nursing facility.
  • The supervising physician must be immediately available while the service is being performed. While they do not have to be in the same room, they must be on-site.

Service

  • The service must be the type of care typically performed in an outpatient setting and not typically self-administered.
  • Supplies are only covered under incident-to if they are commonly found in a doctor’s office.
  • The person who performs the service must be a credentialed medical practitioner employed by or contracted with the same practice as the supervising physician.
  • The service must be a part of the established treatment plan. For example, if a patient sees a nurse practitioner for a follow-up visit and brings up a new complaint, the new complaint cannot be billed incident-to.

Treatment Plan

  • The service must be part of a normal course of treatment for the patient’s condition.
  • The service must be ordered by a Medicare-credentialed physician who has personally examined the patient and established a plan of care.
  • To qualify for incident-to billing, a credentialed physician must establish, manage, and actively participate in the treatment plan.
  • The physician supervising the service does not have to be the same doctor who ordered it. If there is more than one physician working in the same practice, any doctor in the group can act as supervising physician.

Patient Relationship

  • Incident-to services can’t be administered on a patient’s first visit. They can only be ordered for an established patient following a documented plan of care.

Examples of Incident-To Billing

Here are some examples of how incident-to billing might work in various specialties.

  • Ophthalmology: An ophthalmologist saw a new patient with diabetic retinopathy. As part of the treatment plan, the patient is to come back every six months for a screening to monitor the disease.

The screenings are carried out by a technician and the ophthalmologist reviews the results later. These screening visits can be billed incident-to whichever physician is in the office at the time of the visit.

  • Plastic Surgery: A plastic surgery patient returned to the practice three weeks post-procedure for removal of sutures and a check on healing progression. A nurse carried out the suture removal and exam, billed incident-to the surgeon, who was in a different part of the office suite.
  • Dermatology: A dermatologist evaluated a patient with acne and prescribed a treatment. On a follow-up visit, the patient saw a nurse practitioner, who noted the condition was improving and the plan needed no change. This visit can be billed incident-to the dermatologist’s NPI.

But what if the treatment plan was not working? Perhaps the patient was still suffering breakouts and the prescribed ointment was causing irritation, so the nurse practitioner prescribed a different topical treatment.

This represents a new treatment plan, not the one the physician established. This visit cannot be billed incident-to, and must be billed under the nurse practitioner’s own NPI.

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Incident-To Billing Post Pandemic

Though the strain on the U.S. healthcare system has eased since 2020, the staffing shortage remains a very real problem. A booming and aging population is coinciding with the retirement of a generation of physicians, without enough new physicians rising up to fill their ranks.

As a result, the system is becoming increasingly dependent on non-physician personnel. Clinics are vying not only for a limited number of physicians, but also for nurses, therapists, technicians, physician assistants, and other skilled personnel.

While these healthcare professionals can ease the burden on physicians, the incident-to billing requirement that a supervising physician be on-site when services are performed can still be a stumbling block — particularly in medically underserved areas, where services are often performed in patients’ homes and one physician may be responsible for multiple clinic locations.

One gift of the pandemic was rapid advancement of telehealth technology. CMS has proposed extending a temporary rule that permits services to be performed without a supervising physician on premises, as long as the physician is immediately available via telehealth.

The rule has already been extended once before. The current proposal would extend it through the end of 2025. It applies only to a specific subset of incident-to services: those for which the HCPCS code has a PC/TC indicator of 5 and the CPT code is 99211.

Avoid These Common Incident-To Billing Pitfalls

Incident-to billing can help your specialty practice achieve more profitability. Just beware of common mistakes like not following state guidelines, inadequate staff training, and claiming ineligible services.

Not Knowing State Guidelines

Medicare claims are processed by Medicare Administrative Contractors (MACs). These private companies are each assigned a geographic region, where they act as the liaison between healthcare providers and the Medicare Fee-For-Service program.

Each MAC sets its own guidance and policies for how it handles incident-to billing. It’s important to understand the requirements and documentation guidelines specific to your MAC. If you have clinic locations in multiple states, understand the requirements for each region.

 

AB Jurisdictions

 

Not Training Staff to Use Incident-To Billing

Both clinical and administrative staff need to understand who can provide incident-to services and under what conditions.

Train medical staff to document incident-to services in the EHR so the information is communicated to billers.

Train billing staff on the rules and requirements of specific payors. Not claiming incident-to on qualifying services results in lower reimbursements.

Claiming incident-to on services that don’t qualify can lead to more than claims rejection. There are heavy penalties, including paybacks, fines, and even jail time and license suspensions if it’s shown the mistake was intentional.

Set up your EHR and practice management software so that it’s easy for the billing office to keep track of which physicians are supervising which providers, at which location, on which day.

This, along with clear documentation and rigorous training on incident-to requirements, enables staff to verify and defend incident-to billing.

Not Knowing Which Services Are Eligible

Incident-to is not a blanket provision that can be provided to every service in the clinic. Services with their own benefit category, like diagnostic tests, have separate coverage requirements and can’t be billed incident-to.

Simplify Incident-To Compliance

While CMS has established national guidelines for incident-to billing, documentation requirements can vary from state to state.

To complicate matters further, private payers often have their own incident-to guidelines that may be more or less strict than CMS rules.

Billing teams trying to keep all these regulations straight sometimes make mistakes that can lead to claim denial or to the practice being reimbursed at a lower rate.

Robust practice management software simplifies compliance. When a billing system is set up with the appropriate documentation guidelines, it will automate documentation and alert staff to errors or missing information.

A modern EHR is a valuable tool in creating the documentation required to maximize Medicare reimbursements. The requirements of incident-to billing are very particular. Failing to properly document them is likely to lead to claim denial.

An easy-to-use EHR streamlines communication between clinical and billing staff. Providers can note directly in the patient’s chart whether the visit is incident-to a treatment plan, and which physician’s NPI should be used for billing.

This information is communicated to billing staff so they can prepare claims that qualify for full reimbursement.

Schedule a demo to see how Nextech’s specialty-specific EHR and practice management solutions can help your practice maximize profitability.

Frequently Asked Questions

What’s the advantage of incident-to billing?

Incident-to billing allows a non-physician healthcare provider to bill for a service at the full physician fee schedule rate. Without incident-to billing, these professionals are reimbursed at about 85% of the physician rate.

When should I use incident-to billing?

When a Medicare-credentialed non-physician practitioner performs covered in-office services for an established patient, in keeping with a physician-prescribed treatment plan and under a physician’s supervision, it may qualify for incident-to billing. Check the full list of requirements before submitting a claim incident-to.

How do I document incident-to billing?

Incident-to billing documentation should include the information of the physician who ordered the service, the information of the professional who performed it, and the information of the physician who supervised it. Check with your regional MAC for additional documentation requirements.