Does anyone know how to bill incident to for infusion services? I am wondering if my APRN is the first provider in the office when we start administering infusions and the physician comes in after the infusions are started, but he is there when the infusion is completed, who would this be billed under? Also, I am wondering for the reverse, if the physician is in the office when the infusion is started, but leaves before it is finished and the APRN is there when it is finished, who would it bill under? There is a lot of discussion of this, but everyone has conflicting answers.
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Wiki Infusion Billing Incident to
- Thread starter jaimbee78
- Start date
Papitha
Networker
Below the link has very useful information on understanding the rules of 'Incident to Billing'.
If the Provider is 100% accountable for the patient's care and the infusion is managed by the APRN, then it should be billed as "incident to" only.
If the APRN decides on the infusion independantly (not under the Provider's supervision), then it must be billed under the APRN's NPI independantly. "Incident to" is not applicable here.
Hope this helps!
If the Provider is 100% accountable for the patient's care and the infusion is managed by the APRN, then it should be billed as "incident to" only.
If the APRN decides on the infusion independantly (not under the Provider's supervision), then it must be billed under the APRN's NPI independantly. "Incident to" is not applicable here.
Hope this helps!
amyjph
True Blue
The link above in the response is from AAPC 2018.
See the CMS Manuals for 2025 info. There is more than just the snips I took below here to read about in Chapter 12. It depends on the type of procedure, drugs, place of service, etc. You have to read the whole thing in context. Some services may not qualify for incident-to at all. (e.g.; Services which have their own statutory benefit categories)
30.5 - Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions (Rev. 13012; Issued: 12-19-24; Effective: 01-01-25; Implementation: 01-02-25)
"Physician work related to hydration, injection, and infusion services involves the affirmation of the treatment plan and the supervision (pursuant to incident to requirements) of non physician clinical staff."
Another example wording, "The CPT 2006 includes a parenthetical remark immediately following CPT code 90772(Therapeutic, prophylactic or diagnostic injection; (specify substance or drug); subcutaneous or intramuscular.) It states, “Do not report 90772 for injections given without direct supervision. To report, use 99211.” This coding guideline does not apply to Medicare patients. If the RN, LPN or other auxiliary personnel furnishes the injection in the office and the physician is not present in the office to meet the supervision requirement, which is one of the requirements for coverage of an incident to service, then the injection is not covered. The physician would also not report 99211 as this would not be covered as an incident to service."
If the physician is not there the whole time. It is not incident-to. They can't just be there part of the time. However, be sure to read the manuals for exceptions or specific direction related to infusions.
When a patient is seen in a group practice by a NPP, It is acceptable to have an NPP perform an "incident to" service when another physician of the group is in the suite and available for oversight as needed. Group members may provide cross coverage for each other and "incident to" guidelines can be met in this circumstance.
Services performed in the home by auxiliary personnel, such as nurses, technicians, and therapists are covered when performed "incident to" the physician's service only if there is direct supervision in the home by the physician.
See the CMS Manuals for 2025 info. There is more than just the snips I took below here to read about in Chapter 12. It depends on the type of procedure, drugs, place of service, etc. You have to read the whole thing in context. Some services may not qualify for incident-to at all. (e.g.; Services which have their own statutory benefit categories)
30.5 - Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions (Rev. 13012; Issued: 12-19-24; Effective: 01-01-25; Implementation: 01-02-25)
"Physician work related to hydration, injection, and infusion services involves the affirmation of the treatment plan and the supervision (pursuant to incident to requirements) of non physician clinical staff."
Another example wording, "The CPT 2006 includes a parenthetical remark immediately following CPT code 90772(Therapeutic, prophylactic or diagnostic injection; (specify substance or drug); subcutaneous or intramuscular.) It states, “Do not report 90772 for injections given without direct supervision. To report, use 99211.” This coding guideline does not apply to Medicare patients. If the RN, LPN or other auxiliary personnel furnishes the injection in the office and the physician is not present in the office to meet the supervision requirement, which is one of the requirements for coverage of an incident to service, then the injection is not covered. The physician would also not report 99211 as this would not be covered as an incident to service."
If the physician is not there the whole time. It is not incident-to. They can't just be there part of the time. However, be sure to read the manuals for exceptions or specific direction related to infusions.
- Immediately Available: CMS has clarified that "immediately available" means "without delay" so Noridian considers "immediately available" to mean the supervising physician is in the office suite or patient's home, readily available and without delay, to assist and take over the care as necessary.
- Office Suite: An "office suite" is limited to the dedicated area, or suite, designated by records of ownership, rent or other agreement with the owner, in which the supervising physician or practitioner maintains his/her practice or provides his/her services as part of a multi-specialty clinic.
Direct Supervision
Physician must be present in the office suite, immediately available and able to provide assistance and direction throughout the time the service is performed. The supervising physician does not have to be in the same room but must be in the office or clinic.When a patient is seen in a group practice by a NPP, It is acceptable to have an NPP perform an "incident to" service when another physician of the group is in the suite and available for oversight as needed. Group members may provide cross coverage for each other and "incident to" guidelines can be met in this circumstance.
Services performed in the home by auxiliary personnel, such as nurses, technicians, and therapists are covered when performed "incident to" the physician's service only if there is direct supervision in the home by the physician.
During the COVID 19 pandemic, CMS temporarily amended the definition of "direct supervision" to allow the term "immediately available" to be by use of two-way, real-time audio/visual technology. This amendment allowed physicians and other supervising providers to remotely provide direct supervision, as long as they were immediately reachable and able to provide assistance through real-time audio/visual technology. This provision did not allow for audio-only or asynchronous communication such as phone calls or messaging platforms.
There are certain codes that now had these direct supervision flexibilities allowed permanently, as indicated in the 2025 Physician Fee Schedule Final Rule (see below). You can find the PC/TC indicators in the Physician Fee Schedule (I've linked where you can find what the indicators mean).
§ 410.26 Services and supplies incident to a physician’s professional services:
Direct supervision means, except as provided in paragraphs (a)(2)(i) and (ii) of this section, the level of supervision by the physician (or other practitioner) of auxiliary personnel as defined in § 410.32(b)(3)(ii). For the following services furnished after December 31, 2025, the presence of the physician (or other practitioner) required for direct supervision may include virtual presence through audio/ video real-time communications technology (excluding audio-only):
(i) Services furnished incident to the services of a physician or other practitioner when provided by auxiliary personnel employed by the billing practitioner and working under their direct supervision and for which the underlying Healthcare Common Procedure Coding System (HCPCS) code has been assigned a PC/TC indicator of ‘5’.
(ii) Office or other outpatient visits for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care practitioner.
For what it's worth, both 96365 and 96413 have a PC/TC indicator of 5, meaning these are incident-to codes, and therefore the above language would apply. The permanent flexibility would also apply to 99211, as indicated by the language in (ii) above.
There are certain codes that now had these direct supervision flexibilities allowed permanently, as indicated in the 2025 Physician Fee Schedule Final Rule (see below). You can find the PC/TC indicators in the Physician Fee Schedule (I've linked where you can find what the indicators mean).
§ 410.26 Services and supplies incident to a physician’s professional services:
Direct supervision means, except as provided in paragraphs (a)(2)(i) and (ii) of this section, the level of supervision by the physician (or other practitioner) of auxiliary personnel as defined in § 410.32(b)(3)(ii). For the following services furnished after December 31, 2025, the presence of the physician (or other practitioner) required for direct supervision may include virtual presence through audio/ video real-time communications technology (excluding audio-only):
(i) Services furnished incident to the services of a physician or other practitioner when provided by auxiliary personnel employed by the billing practitioner and working under their direct supervision and for which the underlying Healthcare Common Procedure Coding System (HCPCS) code has been assigned a PC/TC indicator of ‘5’.
(ii) Office or other outpatient visits for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care practitioner.
For what it's worth, both 96365 and 96413 have a PC/TC indicator of 5, meaning these are incident-to codes, and therefore the above language would apply. The permanent flexibility would also apply to 99211, as indicated by the language in (ii) above.