EM Coding Alert

Incident-to services are only appropriate for established patients and problems.

If you’re interested in billing incident-to services, and doing so is practical for your specialty and practice, you’re going to need to make sure you’re following the guidelines carefully.

Here are some of the key aspects of providing and billing incident-to services appropriately, according to Shannon O. DeConda, CPC, CPC-I, CPMA, CEMC, CEMA, CRTT, in her HEALTHCON 2025 presentation “Incident-to Services: CMS Billing Provision.”

Abide by Guidelines for Direct Supervision and Established Care

One of the key tenets of incident-to services in most payers’ understanding is that the physician is nearby and can supervise or even intercede as needed.

“As long as there’s a physician in the office, we have a supervising physician … they must be immediately available,” DeConda said.

Beware that sometimes commercial payers’ policies vary in defining immediately available. “There are some commercial carriers that say as long as the physician can be accessed electronically, meaning by phone, email, whatever … but with Medicare, we’re expecting that physician to be in the same general working area,” she explained.

An important aspect of successfully coding incident-to services is making sure there’s an established plan of care. Incident-to does not apply and cannot be used for new patient services, only for established patients. Similarly, new problems usually should not be addressed under incident-to because they often require direct physician service.

Sometimes, a more comprehensively documented treatment plan allows for incident-to services to be rendered even with a “new” issue.

DeConda provided an example: “If the physician wrote a treatment plan that said, ‘I’m putting this patient on this medication. If their blood pressure continues to be elevated, we will try this medication, and if that medication doesn’t work, we’ll just pull the plug.’ So, if the nurse practitioner [NP] is following that treatment plan, it’s still integral to the physician’s created treatment plan.

“That’s the key to incident-to,” she said. “Most people don’t realize or think about creating a treatment plan that dips and goes with the patient, but remember, the physician has to remain part of the patient’s overall care.”

The certainty of the physician managing the patient process is why incident-to services can be paid at 100 percent of the Medicare Physician Fee Schedule Rate, instead of the lower rate for midlevel providers.

Incident-To Isn’t All or Nothing

Having a deep and nimble understanding of incident-to rules is key to rendering and billing these services appropriately.

“You don’t have to bill incident-to or not bill incident-to, but who’s the throttle?” DeConda said. She said that while it may make sense to think of the physician as the determining factor, she believes it’s the NP or physician assistant (PA).

“When they’re in the room seeing the patient, they know right then, even before documentation is made, they know if they met incident-to criteria or not,” she said.

“A telltale sign is to walk into a practice and ask an NP or PA, ‘When you bill your claims, do they go out under your name or not?’ And when they say, ‘Oh, when we meet incident-to, we bill it under my name,’ [you ask] ‘How do you flag those, so somebody knows, or are all of your claims reviewed by a coder or auditor to make sure?’” she said.

If the “throttle isn’t being throttled,” then there probably isn’t sufficient or even any discernment when reporting these incident-to services.

DeConda recommended focusing training on these providers, and maybe even having a poster made that illustrates an incident-to decision tree, so the criteria is near at hand.

It’s also crucial to make sure you’re training midlevel providers to document accordingly, like “Today’s visit was incidental to the plan of care created by Dr. X” or “The provider supervising today is X, and the original date of the plan of care is X, and patient should follow up with the MD.”

This kind of documentation captures the whole situation and can be flagged in billing notes so that coders know under whom that claim should be billed, DeConda said.

And, of course, make sure you’re monitoring all aspects of incident-to services and billing, so you can make sure everyone is on the same page and reporting correctly.

Beware: Billing incident-to does not come without risk. Patients who see a physician’s name on their bill when they know they saw an NP or PA may be suspicious and even report the discrepancy to their payer, which could lead to an external audit.

Note These Considerations for Certain Specialties

Meeting incident-to requirements may not be practical for every practice or even every specialty due to several factors, including supervisory requirements.

Primary care and pediatric practices may find incident-to easy to incorporate because of the nature of routine follow-up visits, DeConda says. Similarly, dermatology and rheumatology practices may be able to implement incident-to services for ongoing treatment plans for patients.

Other specialties, like orthopedics, ophthalmology, ob-gyn, pain management, and general surgery may have more issues in reporting incident-to services, and need to make sure they’re very carefully evaluating each and every opportunity. Practices providing mental health care have “unique considerations” for implementing incident-to services, DeConda said.

Remember: If a physician and a midlevel provider see the patient during the same encounter, then the encounter can no longer be billed under incident-to, because the services rendered could be considered split/shared services.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC