There continues to be some misunderstanding and confusion concerning the “Incident To” billing rules, as well as their relation to the physician “directs supervision of diagnostic test” rule. This article will discuss Medicare’s Incident To rules and offer some suggestions on how to charge private payers.<o:p></o:p></span></p>
Every service provided in the urologist’s office must be charged by a qualified provider, ie, the urologist, a physician’s assistant, or a nurse practitioner. The only mechanism to charge for services provided by a nurse, technician, or other assistant is to charge as if the urologist, physician’s assistant, or nurse practitioner provided the service.
Incident To billing is the term used to describe the act of a qualified provider charging for services provided by another employee. Payment for Incident To services is made at 100% of the physician fee schedule. Note that Incident To is a term and concept peculiar to payers, and Current Procedural Terminology (CPT) does not reference Incident To.
Incident To billing should not be confused with supplies and services that are provided during an office service or procedure provided by a physician. The irrigation fluid, the lubricant, and the nurse who assists the urologist in doing a cystoscopy are all considered Incident To services and supplies. However, the urologist performed the cystoscopy and charges for the service. The supplies and services preformed as a part of the service are not charged separately. They are considered to be a part of the cystoscopy and are paid for as a part of the fee paid to the physician.
Four criteria –
The following are the criteria that must be met before any service performed by non-physician personnel can be billed to Medicare under the Incident To provision:
- The physician must be “immediately available,” defined as being in the office suite (ie, physically and immediately available), but not necessarily directly involved in that patient’s service. Being available in the hospital, in the operating room, by phone at home, or at any other location does not meet this criterion.
- The service must be rendered by an employee of the physician and billed as if the physician performed the service.
- A qualified provider in the practice must have personally seen the patient and initiated a course of treatment.
- The service provided must be a covered service.
These rules should not to be confused with the rules for “physician supervision of diagnostic test.” The diagnostic supervision rules are separate from the Incident To rules for office visits. Although the new diagnostic supervision rules for direct supervision allow certain diagnostic tests to be charged even if the physician is absent for a short period of time, this does not apply to Incident To billing, unless that test is specifically covered under the diagnostic supervision rules.
For example, for 74400-TC, IVP, the technical component is listed under the diagnostic supervision rules as a diagnostic test that requires “direct physician supervision.” The test could be charged even if the supervising physician stepped out of the office for an unplanned short absence. A catheterization, injection, or diagnostic test that is not specifically designated in that category cannot be charged if the supervising physician is absent for any reason.
However, rules in the private sector may be different. Some insurance companies interpret that you are “immediately available” if you are available by phone at a moment’s notice and within a reasonable driving distance to the office. When charging Incident To in the private sector, pay attention to the rules for that specific payer. Some may use Medicare rules.
Non-physician practitioners (eg, physician’s assistants, nurse practitioners, etc.) can bill separately under their provider number for covered medical procedures performed without physician supervision, or the physician can bill for their services as long as the Incident To rules are met.
Scenario examples –
The following are examples that meet the Incident To criteria and should be billed appropriately:
- The nurse administers an injection to a patient that a urologist, Dr. GU, has prescribed for treatment of disease. The patient does not see the physician, but a partner, Dr. Uro, is in the same office suite at the time of the injection. (The service should be charged as if Dr. Uro performed the service.)
- A urologist evaluates a patient, then asks a nurse to insert a catheter.
- A nurse performs a patient’s scheduled cystometrogram and electromyogram for a patient of Dr. GU while his partner, Dr. Uro, is in the office. (The service should be charged as if Dr. Uro performed the service.)
Conversely, here are some examples that do not meet the Incident To criteria and should not be billed:
- A nurse performs a scheduled cystometrogram and electromyogram for a patient while the physician is in surgery at the hospital next door.
- The nurse administers an injection, but there is no physician in the office. However, a physician is at a satellite office across town and is available by phone. (There is a possibility this can be charged to a private payer if it meets their Incident To rules.)
- A new patient comes into the office complaining of burning upon urination. The nurse does a microscopic urine check and notes that the urine is loaded with white blood cells. The nurse starts the patient on phenazopyridine and makes an appointment for the patient to come back the next day to see the physician, who is not in the office that day.
Disclaimer: The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.
