# Incident To-Question



## Angela Schwarzkopf (Nov 13, 2007)

*Incident To - Question*

Help!

If the NP sees Dr. A's patient and Dr. A is not on the premise but Dr. B is on the premise.  Can we bill the service incident to and use Dr. A as the insurance Dr. and Dr. B as the supervising Dr.???


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## kandigrl79 (Nov 13, 2007)

I'm not exactly sure what you mean by "insurance" doctor.  The doctor that you bill as the supervising physician is the doctor that the insurance company or payer will receive.  Medicare says that in order to use a particular supervising physician he must have "direct supervision."  This means that the physician must be present in the office suite and immediately available to provide assistance and direction while the  is performing the service.  If the doctor wasn't present on the premises then you can't use him to bill incident to. I hope this helps...


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## Angela Schwarzkopf (Nov 13, 2007)

Thank you....that is what I thought...but you know how it is - sometimes you need verification because your brain is going "duh".

Respectfully,
Angela N. Andersen, CPC


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## swilliams@img-jax.com (Nov 14, 2007)

*incident to question*

Ok, so I read this post and was thinking the same thing. It was recently asked in my office if Dr A is in the office when the incident to service happens, but we put Dr B's name on the claim, is that OK. I said No, Dr. A would have to be on the claim. 

My boss said at the MGMA conference she was just at in Oct one of the presenters said the rule was recently changed to state that any doctor in the group can be on site and any other doctor in the group can be on the claim. It didn't make any sense to me, but, I went to (with my boss) a presentation last night put on by the medical society and the presenter was a healthcare attorney who agreed with my boss. The attorney said that FCSO (our local carrier) did write a rule that allowed this type thing to be ok.

I can't find anywhere on the local carrier's website or the CMS website to support this. Can anyone help me prove or disprove this.

Thanks,
Stacy


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## safnlp (Nov 15, 2007)

*stacey_cpc*

The rule is whoever is covering for the dr that is out of the office you would have a supervising dr for the day and bill under that drs # and that dr who is covering for that day would sign off on the chart. It can not be a new problem it has to be an established plan of care. What we have are NPS do is write on the fee slip who is covering that day and then we change it to that drs # and the NP gives the chart to the supevising physician to sign off.
If the NP  sees the pt for a new problem then it must be billed under the NPs medicare #
If the DR is out of the office you can not bill under that DRs # you have to use the supervising DR no the claim


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## Youngmedconsult (Nov 18, 2007)

*Supervising Physician*

The NCD from Medicare on Incident To services PHYS-004 states the following.

2. In some cases the physician or nonphysician practitioner who performed an initial service and ordered the service that is subsequently performed by auxiliary personnel is not the same person who is supervising the service. Then the supervising physician must be identified on both the paper and electronic claim forms. 
a. When the paper Form CMS 1500 is used, follow the instructions for completing the form, found in Pub 100-04, chapter 26, §10.4 : When a service is incident to the service of a physician or non-physician practitioner, the name and assigned UPIN (the NPI shall be used when implemented) of the physician or non-physician practitioner who performs the initial service and orders the non-physician service must appear in items 17 and 17a.
b. When filing electronic claims with incident to services, supply the ordering physician information for each line of service in the 2420E loop and supply the supervising physician information in loop 2310E. If the supervising physician information differs for a specific detail line, then supply that detail line supervising physician information in loop 2420D

So you bill under the supervising physician that is present but note the physician who is following the patient in Box 17 and 17A

I hope this helps

Jill Young


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## swilliams@img-jax.com (Nov 19, 2007)

*thanks*

Jill,

Thanks for outlining it for me. I just needed to see it in official writing.

Thanks a bunch,
Stacy


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## skincer (Dec 12, 2007)

*"Incident-to" services*

The billing of “incident-to” services must be reported under the supervising physician name and ID#. Therefore, services rendered “incident-to” can be ordered by one physician and supervised by another.  The Medicare Benefit Policy Manual, Chapter 15, Section 60.3 provides the following information (see sections 60.1 through 60.3): 


_“In highly organized clinics, particularly those that are departmentalized, direct physician supervision may be the responsibility of several physicians as opposed to an individual attending physician. In this situation, medical management of all services provided in the clinic is assured. The physician ordering a particular service need not be the physician who is supervising the service. Therefore, services performed by auxiliary personnel and other aides are covered even though they are performed in another department of the clinic.”_


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## mcpalmeter (Dec 20, 2007)

Angela Andersen said:


> Help!
> 
> If the NP sees Dr. A's patient and Dr. A is not on the premise but Dr. B is on the premise.  Can we bill the service incident to and use Dr. A as the insurance Dr. and Dr. B as the supervising Dr.???


Hi Angela,

I think you will find the answer you are looking for in the Medicare Benefit Policy Manual Chapter 15, Section 60.3 where it is stated:

In highly organized clinics, particularly those that are departmentalized, direct physician supervision may be the responsibility of several physicians as opposed to an individual attending physician. In this situation, medical management of all services provided in the clinic is assured. The physician ordering a particular service need not be the physician who is supervising the service. Therefore, services performed by auxiliary personnel and other aides are covered even though they are performed in another department of the
clinic.

Further guidance on whose NPI needs to be reported where can be found in the Medicare Claims Processing Manual, Chapter 26, Section 10.4 Items 17, 17a, 17b, and Item 24J.  

These guidelines instruct on where to enter the NPI of the provider who ordered the service and where to enter the NPI of the provider supervising the service if the supervising provider is other than the physician who ordered the service (i.e., if the supervising provider is other than the physician who the service is being rendered incident to).

Best regards,

Maryann Palmeter


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## djzetter (Dec 28, 2007)

*Incident-To- question*

Another thing to be aware of is that you will want to make sure that all the physicians in the group, other than the supervisiing physician, are listed as assistant supervising physicians within your supervision/employment agreement with the PA and that this is filed with your state medical/osteopathic board.  If you use a physician as a supervisor and they are not listed with your medical board as a supervising physician, then you are not compliant with state laws.  This is the way it works in several states in which I have clients.  You will need to check the state code and medical or ostepathic board regulations as these are usually more stringent than Medicare reimbursement regulations.

Hope this helps.


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## k205412 (Jan 4, 2008)

*Incident Too*

*Thank you AAPC for making it more clearer on the "Incident Too" ruling. Do you have any information from CMS re: ruling change to allow any provider within the group or any provider can be on site on the claim. *

Thanks
Belinda Vargas
partyoffive2@verizon.net


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## shenning (Jan 4, 2008)

*incident-to*

Medicare B New Issue 214 August 25, 2004


Related Change Request (CR) #: 3242                        Medlearn Matters Number: MM3242

Related CR Release Date: June 18, 2004

Related CR Transmittal #: 17

Effective Date: October 4, 2004

Implementation Date: October 4, 2004



Instructions for Providing Supervisor's Information When a Service Incident to the Ordering Physician Is Supervised by Another Physician in the Group



Provider Types Affected

Physicians and non-physician practitioners



Provider Action Needed

Physicians and non-physician practitioners should note that this instruction clarifies that the supervisor's identification is required on a claim when a service performed incident to the service of one physician or non-physician practitioner is supervised by another member of the same group.  It instructs how to report ordering physician and supervising physician information on the electronic claim form.



Background

The preamble of the proposed rule for the Medicare Physician Fee Schedule on November 1, 2001 (66 Fed Reg. 55267) stated: "The billing number of the ordering physician (or other practitioner) should not be used if that person did not directly supervise the auxiliary personnel."



This rule was included by the Centers for Medicare & Medicaid Services (CMS) to give instructions for providing the supervisor's information on the CMS paper claim form (CMS-1500). Details regarding how to complete the paper claim form 1500 can be found in the Medicare Claims Processing Manual, Publication 100-04, Chapter 26 (Completing and Processing Form CMS-1500 Data Set), Section 10.4  (Items 14-33 - Provider of Service or Supplier Information). This CMS manual can be found at the following CMS web site:



http://www.cms.hhs.gov/manuals/104_claims/clm104index.asp


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## MarieCoderII (Jan 23, 2008)

*incident to*



kandigrl79 said:


> I'm not exactly sure what you mean by "insurance" doctor.  The doctor that you bill as the supervising physician is the doctor that the insurance company or payer will receive.  Medicare says that in order to use a particular supervising physician he must have "direct supervision."  This means that the physician must be present in the office suite and immediately available to provide assistance and direction while the  is performing the service.  If the doctor wasn't present on the premises then you can't use him to bill incident to. I hope this helps...



I totally agree with everything Kandigrl79 wrote.  I just want to add that since Dr B was the one present to comply to the incident to rule, Dr B must be used as the supervising physician when billing for the service...
Marie L., CPC


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## dwillis (Jan 24, 2008)

*Physician's Office / Clinic vs. Facility / Outpatient*

Can someone clairify this further in that these  responses are based on a physician's office or clinic.  It is my understanding that the "incident to billing" regulations do not apply to facility billing in the outpatient setting.


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## member7 (Feb 23, 2008)

If you haven't already, refer to the following link of the Medicare Benefit Policy Manual and see if that is helpful for you in terms of the incident to for institutions.  See section 60.  

http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf


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## amiles02 (Apr 12, 2008)

*Incident to in Provider Based Clinic*

The incident to rule in location of "provider based clinic" just recently changed.  As you can see below, the "treating physician" must be present in order to bill the incident to.  

20.5.1- Coverage of Outpatient Therapeutic Services Incident to a Physician's Service Furnished on or After August 1, 2000
(Rev. 82; Issued: 02-08-08; Effective: 01-01-08; Implementation: 03-10-08

Therapeutic services and supplies which hospitals provide on an outpatient basis are those services and supplies (including the use of hospital facilities) which are incident to the services of physicians in the treatment of patients. Such services include clinic services and emergency room services. Policies for hospital services incident to physicians' services rendered to outpatients differ in some respects from policies that pertain to “incident to” services furnished in office and physician-directed clinic settings. See the Medicare Policy Manual, Pub 100-02, Chapter 15,“Covered Medical and Other Heath Services”, section 60.
To be covered as incident to physicians' services, the services and supplies must be furnished by the hospital or CAH or under arrangement made by the hospital or CAH (see section 20.1.1 of this chapter). The services and supplies must be furnished as an integral, although incidental, part of the physician's professional service in the course of treatment of an illness or injury.
The services and supplies must be furnished in the hospital or at a department of the hospital which has provider-based status in relation to the hospital under 42 CFR §413.65 of the Code of Federal Regulations. The services and supplies must be furnished on a physician's order (or on the order of nonphysician practitioners working within their scope of work and the state and local policies) by hospital personnel and under a physician's supervision, as described below. This does not mean that each occasion of service by a nonphysician need also be the occasion of the actual rendition of a personal professional service by the physician responsible for care of the patient. However, during any course of treatment rendered by auxiliary personnel, the physician must personally see the patient periodically and sufficiently often to assess the course of treatment and the patient's progress and, where necessary, to change the treatment regimen. A hospital service or supply would not be considered incident to a physician's service if the attending physician merely wrote an order for the services or supplies and referred the patient to the hospital without being involved in the management of that course of treatment.
The physician supervision requirement is generally assumed to be met where the services are performed on hospital premises. The hospital medical staff that supervises the services need not be in the same department as the ordering physician. However, if the services are furnished at a department of the hospital which has provider-based status in relation to the hospital under 42 CFR 413.65 of the Code of Federal Regulations, the services must be rendered under the direct supervision of a physician who is treating the patient. “Direct supervision” means the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed


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## rthames052006 (Apr 13, 2008)

djzetter said:


> Another thing to be aware of is that you will want to make sure that all the physicians in the group, other than the supervisiing physician, are listed as assistant supervising physicians within your supervision/employment agreement with the PA and that this is filed with your state medical/osteopathic board.  If you use a physician as a supervisor and they are not listed with your medical board as a supervising physician, then you are not compliant with state laws.  This is the way it works in several states in which I have clients.  You will need to check the state code and medical or ostepathic board regulations as these are usually more stringent than Medicare reimbursement regulations.
> 
> Hope this helps.



David is correct in what he is saying here, in our practice only the "partners" are supervising doctors and when our office schedule is made up, it list who is the "supervising doc" not just for billing incident to services but as a "go to doc" for that particular day.... it actually works out for us.

Just my opinion


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## Glenda Hamilton (Apr 20, 2008)

*Clinical Documentation Educator*

According to CMS guidelines, and most state guidelines, If the NP's scope of practice is with the "group entity" and you are billing "Incident To" which means the bill is being dropped under the billing (on-site) NPI number. Remember the 4 basic guidelines, est pt., est problem, physician in the site and out-patient only. You should be good to go.


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## jenn13088 (May 19, 2008)

Roxanne, 
Our practice does the same.  We have one doc listed as the supervising physician for the day that the NP's and our EPO clinic bill under UNLESS the attending is present in the office.  It has helped us out tremendously!!

Jennifer Sprague
CPC-A
Syracuse, NY


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## jenn13088 (May 19, 2008)

One more note, there are updates to the "incident to" rules that go into effect June 2, 2008.  You can find them on the national website at: http://www.cms.hhs.gov/Transmittals...descending&itemID=CMS1210290&intNumPerPage=10

Jennifer Sprague
CPC-A
Syracuse, NY


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## gcaron (Jul 18, 2008)

*"Incident to" Glenda's rule of NP*

Hi there,
What I teach my mid-level providers is just to remember the initials NP to know the services for which they have to bill under their own provider #

-*N*ew *P*t.   
-*N*ew *P*roblem 
-*N*o *P*hysician present


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## DonnaStevens (Aug 6, 2008)

*incident*

can np see patients in nursing homes?? if the np saw the established patient then she would be billing under her #. It really cant be incident to as the dr would not be at the nursing home at the same time she would be there. If that would be the case why use an np?

Can you use split visits at a nursing home? for example the np sees the pt which is established and writes up the chart work and the dr signes off on this. in order to be split visits if allowed in a nursing home. shouldnt the dr have a face to face with the patient and not just sign off on the char.

I am confused.  any advise would be greatly appreciated.


Thanks 

Donna


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## mkartrude (Sep 24, 2008)

*is a signature needed?*



jenn13088 said:


> Roxanne,
> Our practice does the same.  We have one doc listed as the supervising physician for the day that the NP's and our EPO clinic bill under UNLESS the attending is present in the office.  It has helped us out tremendously!!
> 
> Jennifer Sprague
> ...



Is it required that the supervising physician sign the PA's documentation?
If so, where can I find this info to show documentation to our physicians?
also, are eletronic signatures exceptable?
mkartrude cpc


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## tammyboyer (Sep 28, 2008)

*incident to*

you will bill with Dr B


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## smuckers (Feb 19, 2009)

*dx for kennedy terminal ulcer*

I'm looking for diagnosis for "kennedy terminal ulcer",is their one.\
Thanks, 
Deanna


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## rthames052006 (Feb 19, 2009)

smuckers said:


> I'm looking for diagnosis for "kennedy terminal ulcer",is their one.\
> Thanks,
> Deanna



Your posting in the wrong discussion group.


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## wmartinez (Feb 25, 2009)

*Incident to Services*

Im curious to know what the answer was for incident to services, if the  supervising physician needs to sign the PA's documentation?
If so, where can I find this info to show documentation to our physicians?


I would appreciate any help.

Thanks

Wendy M.


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## 00052616 (May 15, 2009)

*Documentation and Billing for RN or LP changing Foley*

If an RN is changing a Foley Catheter, under the presence of the ordering 
provider. Can we bill this service (facility charge only) this is a hospital based clinic. Would we use an E& M (99211 for the RN service)  billing under the physcian who was present and placed the order?

What documentation would be required.. our note by the RN identifies the name of the physcian and states that he was present. Is there any documentation requirements by the Physcian ..addendum or signature required as long as we have his order for this service?


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## sparkles1077 (Feb 27, 2010)

*99211 billable in facility based clinic*

Just wondering if an answer was found about billing a 99211 in a facility based clinic?  Can only the facility fee be charged since it is the facility setting?  Can indicent to requirements be fulfilled in a facility based outpatient clinic?

Thanks!!!


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## mitchellde (Feb 28, 2010)

Incident to does not apply to the facility billing only the professional billing.  A facility may bill a 99211 if the facilities requirements for that level have been met.


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