"Incident to" is a Medicare billing provision that allows services provided by PAs in an office or clinic setting to be reimbursed at 100 percent of the physician fee schedule by billing using the physician's NPI. The Medicare Benefit Policy Manual defines "incident to," in part, as "services furnished as an integral although incidental part of a physician's personal professional service."
To bill Medicare "incident to" for services provided by a PA the following criteria must be met:
- The service performed must be one that is typically performed in a physician's office.
- The service performed should be within the scope of practice of the PA and in accordance with state law.
- The physician must personally treat the patient on the patient's first visit to the practice or treat any established patient who comes to the office wit a new medical condition. PAs may provide follow-up care.
- The physician should be in the suite of offices (on-site) with the PA is rendering the service.
The physician must continue to see the patient at a frequency that reflects ongoing management of the patient's care. Medicare's "incident to" policy may be found in the August 28, 2002 transmittal, 1764 at this link: http://www.cms.hhs.gov/transmittals/downloads/R1764B3.pdf.
Example: A Medicare patient has been previously treated by the physician and diagnosed with hypertension. On a subsequent visit to the physician's office a PA saw the patient and evaluated his or her hypertension within the plan of care established by the physician on the initial visit. The physician or another physician within the group was on-site, within the suite of offices at the time the PA saw and treated the patient. The PA may bill the office visit, "incident to," under the physician's NPI with full reimbursement.
Frequently Asked Questions about "Incident to"
May a physician assistant (PA) see a new Medicare patient and bill the service "incident to?"
No. By definition, a practice cannot bill a new patient visit with a PA under the NPI number of the PA's supervising physician.
Can a PA see a new Medicare patient? What about a Medicare patient who comes to the office when no physician is on-site?
Yes. A PA may see and treat any Medicare patient and provide a service within his or her state law guidelines for scope of practice as long as the state's supervision requirements are met. Since the "incident to" criteria have not been met, the claim should be submitted with the PA's NPI.
If a patient was initially diagnosed by one physician in a group practice and a PA sees the patient for a follow-up visit for the same condition while a different physician in the group is within the suite of offices, may the service be billed "incident to?"
Yes. In Medicare's eyes, all physicians within a group are interchangeable. In this situation the claim should be submitted with the NPI number of the physician who was within the suite of offices while the "incident to" visit took place.
What should be done if a PA is seeing an established Medicare patient with an established problem for an "incident to" visit and the patient begins to describe a new condition that is unrelated to the physician's previous diagnosis?
The PA has the following options: 1) see and treat the patient for the new condition and bill for this and subsequent visits for the new problem with his or her NPI or 2) have the physician see and treat the patient for the new problem in order to establish a diagnosis so that future visits with the PA for this new problem can be billed "incident to" as long as other "incident to" criteria are met.
After an initial visit, what role should the physician have in a Medicare patient's ongoing care while the PA see the patient "incident to?"
The medical record should reflect that the physician has an "ongoing involvement in the patient's care."
Some private payers in my state require that claims for visits with PAs be submitted with the billing number of the supervising physician. Does this mean that PAs cannot see new private insurance patients or private insurance patients who come for visits when no physician is present?
No. "Incident to" is a Medicare billing provision. Requirements that physicians establish diagnoses and be on-site apply only to Medicare patients, unless otherwise specified by the private payer or state laws. If a private payer uses the term "incident to," always ask for clarification of the billing requirements; do not assume that Medicare rules apply.
"Incident to" is confusing! May a practice submit claims for all Medicare patient visits with PAs under the PA's NPI?
Yes. Some practices choose to forego the additional 15 percent reimbursement to simplify billing. In their view, the increased volume of patients treated by the PA leads to enhanced revenue, making up the 15 percent differential, and reduced patient wait times.
