What is incident-to billing? How to bill it?

Touseef Riaz

September 20, 2022

incident-to billing

Billing the medical service is a complex process. It is because there can be different criteria for the billing for the services undertaken by the physician or a non-physician practitioner. For example, one complex billing process is incident-to billing which requires meeting specific criteria under which the bill is formed.

It is necessary to understand what it is and its requirements for incident-to billing. Here are the incident-to-billing guidelines 2022, which should be a consideration

incident-to-billing-ucb

What is incident-to billing? 

Usually, when you go to a hospital, the physician can charge 100 percent reimbursement for the service provided; however, if this service takes place by a hospital member, a non-physician practitioner (NPP). In that case, the reimbursement can reduce to 85 percent rather than the actual 100 percent amount. Therefore, it can be necessary for the hospital to keep using the NPP to provide services in emergency cases as they can help enhance productivity in the hospital or the physician’s office. 

The hospital treating patients in an emergency might be possible that some of the doctors in the facility are unavailable due to the extensive crowd. For example, on New Year’s Eve, the doctors report having more patient flow in an emergency than usual. Therefore, there is a need to use the NPP to provide services to the patients, which can be of similar expertise as the physician in similar situations.

In the case of NPP treating the patient, there can be ways in which full reimbursement of the fee occurs. For example, incident-to billing can provide over 100 percent reimbursement for the service offered by the non-physician service rather than 85 percent. 

These procedures tend to come under the Medicare rules, and a non-physician provides specific services. This rule provides an exception for the non-physicians under the Medicare Benefit Policy Manual, i.e., “Services and supplies furnished incident to a physician’s/NPP professional service.” This cause comes in Chapter 15, Section 60 of the manual that states the incident-to billing rules. It is mentioned that specific regulations must be met to make the 100 percent reimbursement successful. 

Example of incident-to billing 

The incident-to billing can also be understood with the help of an example. For instance, if a nurse, also known as the NPP, is providing the service to a patient with a simple fever, then the incident-to billing can be exploited. In this situation, it becomes essential that the patient has no serious health issues and the NPP is taking the measures that the physician has directed under certain circumstances. Such situations can include the billing under the physician’s NPI, which would be charged as 100 percent rather than 85 percent, which NPP sets. 

How to bill it? 

The Medicare Benefit Policy Manual has detailed requirements that must be met if the medical practitioner is exploiting the incident-to billing. Unfortunately, if any of these requirements are not met by the practitioner, the total reimbursement cannot be charged to the patient. In such a case, the patients can claim the 15% fee set for them as they have not been provided the expected service that Medicare Benefit Policy Manual promised. 

There are majorly seven requirements that need to be met by the medical facility to deploy the incident-to billing. These requirements have been discussed below. 

Requirements for billing incident-to? 

Requirement # 1

The first and significant requirement of incident-to billing is that this billing can only be suited for professional services under Medicare. Other categories are not entertained with this benefit as the services are not meant to be delivered by the NPP in these categories by Medicare. 

It can include specific services like diagnostic tests. Therefore, it is essential to be familiar with the benefits that come under Medicare so that the patients can know what they need to bill for the service they have undertaken in a particular facility or hospital. 

Requirement # 2: 

Another requirement to be met is that the service must be undertaken in a non-institutional setting. Medicare has already highlighted these institutions in their manual so that the confusion related to the service can be removed. Most majorly, these institutes are the ones other than the hospitals and nursing facilities. 

Under the manual, it is also directed that the practitioners can fully reimburse the partial hospitalization services mentioned in the incident-to manual. However, the service must be taking place in the non-institution. 

Requirement # 3

It is also essential that the Medicare-credentialed physician initiates the patient care. In this case, if the patient tends to have a severe complaint that the NPP can not treat, then it is essential that the physician conducts the initial evaluation of the patient and makes the diagnosis. It also includes the planned procedure, which the physician directs for patient care, which the NPP can implement. 

In such a case, it is essential to note that the incident-to service is not rendered on the patient’s first visit. It also includes evaluating whether a change of plans is required for the patient in the future. 

Requirement # 4

The following requirement is that, after the initial diagnosis and plan provided by the physician, the NPP can provide the follow-up care for the patient in the service. In this case, it is important to note that it is not essential that the physician is present in the room while the NPP is providing care to the patient. 

The physician must be available in the office if the NPP requires immediate help in implementing the care plan. In addition, it means that the qualified provider must present for the direct supervision of the NPP in case of providing service. 

Requirement # 5

The physician needs to participate actively and manage the patient’s course of treatment. The individual state licensure rules give this requirement much importance for physician supervision of NPPs which means this criterion must be met. 

It includes the criteria in which the physician needs to be available to check the patient every third visit. Therefore, it is safe to say that physician’s help is required if the patients are being treated in the institution. Consequently, one can make full reimbursement of the fee with these criteria.

Requirement # 6

It is also essential that the credentialed physician and the qualified NPP providing the incident-to service in the facility are employed by the group entity billing for the service. In this clause, if the physician is a sole practitioner, then there is a need for the physician to employ the NPP. Thus, credentialed physicians and qualified NPP are considered necessary in providing the service to patients. 

Requirement # 7

The last requirement is that incident-to-service needs to be of a type usually performed in the office setting. It should also be part of the ordinary course of treatment of a diagnosis or illness. As directed in the manual, the incident-to billing will not be applicable if any service has occurred outside of the office setting. 

These are several requirements under the Medicare Benefit Policy Manual criteria for incident-to billing

It shows the various ways in which incident-to billing is used by the medical service provided. It includes charging the patient with full fee even if the non-physician offers the service. Still, the patient needs to know their right to the actual price that is authorized to them. With the above discussion, it becomes clear that incident-to billing is essential to be understood by both patients and physicians to evaluate the basic billing rules before making any decisions. 

References:

CMS (2009), Medicare Benefit Policy Manual: Chapter 15 – Covered Medical and Other Health Services

FAQs

What is the incident to billing?

Incident to billing refers to billing outpatient services provided by a non-physician like a nurse practitioner, physician assistant, or any other non-physician. 

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