Revenue Cycle Insider

See how you can bill more services at 100 percent of the physician fee schedule instead of 85 percent.

If you’re not already billing incident-to services in your practice, you could possibly bring in more money. However, there are specific rules for distinguishing and billing incident-to services that may seem confusing.

Read this first article in a two-part series for some easy-to-digest information on billing incident-to services successfully, provided by Shannon O. DeConda, CPC, CPC-I, CPMA, CEMC, CEMA, CRTT, in her HEALTHCON 2025 presentation “Incident-to Services: CMS Billing Provision.”

Know the Fundamentals

Basically, billing incident-to services means that you’re billing for a service by someone who did not render the care. “The person who actually went into the room, or did whatever face to face with the patient, is not the person who’s on the claim form,” she explained.

Auxiliary or ancillary staff is anybody for whom you can bill incident-to, as opposed to nonphysician practitioners (NPPs) like nurse practitioners (NPs), physician assistants (PAs), and  certified nurse midwives (CNMs), who can bill directly for their services.

Incident-to may involve ancillary staff who check a patient in and get their vitals documented, which can count toward the evaluation and management (E/M) service. But sometimes such staff cannot bill anyway, which is why the service is incident-to and counts toward the physician service. “Most organizations do this because of the variance in reimbursement rate,” said DeConda.

Incident-to billing can be reimbursed at 100 percent of the Medicare Physician Fee Schedule (MPFS), whereas practitioner direct billing, like for NPPs, is reimbursed at 85 percent, a reduced fee schedule.

“The reason we can get paid 100 percent for incident-to is because the physician created the treatment plan. Everybody who’s performing services under that are following the MD-blessed treatment plan — all the work they’re doing is integral to that treatment plan,” she explained.

Remember, too, that incident-to is not a coding rule. “We have coding rules that say, ‘this is how you use the code,’ and we have reimbursement policy, which says, ‘if you’re going to bill this code, this is how we’ll pay for this code.’ Incident-to is completely payer policy; there are some payers who will not pay incident-to,” DeConda said.

Tip: “When it comes to modifier usage, when it comes to credentialing or not credentialing — by the way, they should all probably be credentialed — look at your carriers for that variance,” DeConda said.

Incident-to rules vary by payer, and while it may be easiest to just apply the strictest standards across the board, taking the time to figure out each payer’s rules can actually simplify your billing strategies.

Understand Incident-to Necessity

DeConda said billing a service as incident-to can be simplified by asking two questions: Was it necessary and does the situation meet the criteria?

She defined necessity as “Service must be an integral part of the physician’s professional services. It should commonly be included in their standard billing pattern. This includes services that are a necessary component of the physician’s treatment plan.” The criteria she mentioned: “Services must be reasonable and necessary for the diagnosis or treatment of the patient’s condition. They must follow accepted medical practices. They must also be within Medicare’s scope of covered services and not specifically excluded from coverage.”

When thinking about necessity, anchor any incident-to services to the treatment plan. “If the treatment plan falls apart, if it needs to be changed, if it needs to be modified, it’s no longer an integral part of that treatment plan. Go back to the treatment plan: That’s the cornerstone of incident-to,” she said.

Meet the Criteria

When considering criteria, think about supervision, the physician’s role in treatment, and the employment relationship between the physician whose name is on the claim form and the NPPs and ancillary staff who are providing the services.

Tip: It’s also important to be aware of how scope of service may affect your billing strategies. It’s not necessarily the job of a coder or auditor to know state licensure or scope of work, but since it inevitably comes up, DeConda recommends bookmarking your state’s scope of licensure page so you can easily check what NPPs and other staff like lab techs or registered nurses (RNs) can do.

Caveat: Providing and billing mental health services is a “horse of a different color,” DeConda said. You’re going to need to check individual carriers because they may not recognize certain certifications.

In terms of supervision, MDs need to be within the same general space as whoever is performing the incident-to services. If an MD is performing surgery on one side of the building, they cannot actually or effectively supervise the PA who’s seeing patients. You could still bill for the PA’s time and effort, but you’d have to do so via direct billing instead of incident-to.

To bill incident-to services, the physician needs to be involved in treatment beyond just setting the plan, so they should probably see the patient at least occasionally. DeConda said the Medicare Administrative Contractor (MAC) Noridian used to recommend on their website to follow a rule of threes: every third visit the patient needs to be seen by the physician, so they remain integral to patient care.

Remember, too, that there has to be an employment relationship between the physician and the NPP or ancillary staff; otherwise you risk violating Stark rule. This also means that you need to have your providers’ tax identification numbers (TINs) organized accordingly: If your physicians have a different TIN than the NPPs in the practice and the physical space, then you may run into compliance trouble if trying to bill incident-to.

Check back next month for more information on billing incident-to services.

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