Rheumatology Practice Management June 2017 Vol 5 No 3 - Billing Update
Candice Fenildo, CHC, CPC, CPMA, CPB, CPC-1, CRHC, AAPC Fellow
Associate Consultant, Acevedo Consulting, Delray Beach, FL

Advanced registered nurse practitioners and physician assistants are being used more and more in physician practices. Medicare has strict guidelines for when services can be billed under the physician’s National Provider Identifier (ie, services rendered “incident to”).

“Incident to” services are defined as services that are furnished incident to physician professional services in the physician’s office. These services are paid at 100% of the physician fee schedule, whereas services reported by nonphysician practitioners are paid at 85%.1

Depending on who actually performed the service, erroneous reporting could result in a 15% or 100% overpayment. To qualify as “incident to,” services must be part of the patient’s normal course of treatment, during which time a physician personally performs an initial service and remains actively involved in the course of treatment.1 Although the provider does not need to be physically present in the patient’s treatment room while these services are provided, the provider must offer direct supervision, and, therefore, be present in the office suite to render assistance, if necessary. “Incident to” services are performed in the office and the home settings.

The requirements for “incident to” include1:

  • The nonphysician practitioner must be employed by the practice
  • The nonphysician practitioner must be enrolled in Medicare
  • The patient must be an established patient to the physician
  • There must be a plan of care established by the physician
  • The patient must be treated for an established problem and follow the plan of treatment prescribed by the physician
  • The physician must provide direct supervision.

It is important that your documentation identifies who rendered the service, indicates that the supervision requirement is met, shows the physician’s initiation and continued involvement in treatment, and demonstrates that the treatment is reasonable and necessary and the services are within the scope of practice of your nonphysician practitioner. For Medicare purposes, the medical doctor or doctor of osteopathic medicine is not required to sign documentation prepared by the nonphysician practitioner.

Furthermore, nurse practitioners, clinical nurse specialists, and physician assistants are not defined as physicians under §1861(r) of the Social Security Act.2 Therefore, they may not function as supervisory physicians under the diagnostic tests benefit (ie, §1861[s][3] of the Act). However, when these practitioners personally perform diagnostic tests as provided under §1861(s)(2)(K) of the Act, §1861(s)(3) does not apply and they may perform diagnostic tests pursuant to their state scope-of-practice laws and under the applicable state requirements for physician supervision or collaboration.

Because the diagnostic tests benefit set forth in §1861(s)(3) of the Act is separate and distinct from the “incident to” benefit set forth in §1861(s)(2) of the Act, diagnostic tests need not meet the “incident to” requirements. Diagnostic tests may be furnished under situations that meet “incident to” requirements, but this is not required. However, insurance carriers must not scrutinize claims for diagnostic tests using the “incident to” requirements.

You have 2 choices here; submit all claims under the nonphysician practitioner’s own provider number and accept 85% reimbursement, or educate your nonphysician practitioner about “incident to” rules and let the nonphysician practitioner decide if the established patient visit meets the requirements of “incident to” billing.


  1. Centers for Medicare & Medicaid Services. “Incident to” services. Updated August 23, 2016. work-MLN/MLNMattersArticles/downloads/se0441.pdf. Accessed May 19, 2017.
  2. Centers for Medicare & Medicaid Services. Medicare claims processing manual: chapter 12 - physicians/nonphysician practitioners. Updated August 12, 2016. Accessed May 19, 2017.
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Last modified: June 28, 2017
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