Originally published January 12, 2017. CMS has since changed split/shared visit rules (billed by whoever performs the substantive portion) and temporarily allowed virtual direct supervision. Payer rules change; confirm current CMS and payer requirements before billing.
Medicare allows two ways to bill for services by non-physician practitioners (NPPs): directly, under the NPP's own name and NPI, or "incident to," under the supervising physician's name and NPI.
Incident-to services are furnished as part of the physician's professional services in the physician's office (whether a separate office suite or within an institution) or in the patient's home.
NPPs include nurse practitioners, physician assistants, clinical nurse specialists and certified nurse-midwives. Medicare pays 100% of the fee schedule for incident-to services billed under the physician's NPI, and 85% for services billed under the NPP's own NPI. Certified nurse-midwives are the exception: they are paid directly at 100% of the physician fee schedule for their own services and services incident to them.
Medicare incident-to requirements
- The NPP is a W-2 employee, or a leased employee with a written contract.
- Services are provided in the physician's office or clinic and are an integral part of the physician's treatment plan.
- The physician performed the initial service and established the diagnosis and treatment plan.
- The physician sees established patients for the first visit for any new problem.
- The physician, or another physician in the group, is on site while the NPP sees the patient.
- The physician continues to see the patient in a way that shows ongoing involvement in care.
Co-signing the NPP's note, briefly meeting the patient or co-visiting doesn't meet the requirements. The physician's initial and new-problem visits must be face to face.
Incident-to billing does not apply in a hospital setting.
Split/shared visits
Unlike incident-to, split/shared services can be reported in the ED, inpatient or outpatient hospital setting. These are E/M services that a physician and NPP provide jointly on the same day. Both must see the patient face to face and document their portion, and the level of service is based on the combined notes. If only the NPP sees the patient that day, the service is billed under the NPP's NPI.
Commercial payers
Private payers don't all follow Medicare's incident-to rules (Aetna is an exception and has adopted Medicare's policy). Commercial payers usually handle NPPs in one of two ways:
- Enroll NPPs, and the practice bills under the NPP's NPI and the group TIN.
- Don't enroll NPPs, and the practice bills under the supervising physician's name and NPI.
In many markets, payers such as Aetna, Cigna, BCBS, 1199, UHC, Fidelis and EmblemHealth credential NPPs, but not all follow Medicare's incident-to guidelines. For example, BCBS requires NPPs who are eligible for their own NPI and recognized by the plan to bill under their own NPI.
In most cases, if the payer doesn't credential NPPs, the claim is billed under the physician's NPI even if incident-to requirements aren't met.