Incident-to Billing

A Medicare billing arrangement where services provided by qualified staff under a physician's direct supervision are billed under the physician's NPI at the physician's full fee schedule rate.

Incident-to billing is a Medicare provision that allows certain services provided by non-physician practitioners like nurse practitioners, physician assistants, and clinical staff to be billed under the supervising physician's NPI at 100% of the Medicare fee schedule. Without incident-to, NPs and PAs bill under their own NPI at 85% of the physician rate. The rules for incident-to are strict. The physician must have performed the initial service and established the plan of care. The physician must be physically present in the office suite (not necessarily in the room) when the incident-to service is provided. The service must be part of the physician's ongoing treatment plan. The patient's condition must be stable. If the patient presents with a new problem, the service cannot be billed incident-to. Incident-to only applies to office and clinic settings. It does not apply in hospitals, emergency departments, or skilled nursing facilities. It only applies to established patients. New patient visits must be performed by the billing provider. Why does this matter for credentialing? Because incident-to affects how your practice enrolls its providers with Medicare. If you use incident-to billing, your NPs and PAs may not need their own Medicare enrollment for the services billed incident-to. However, they still need to be enrolled in PECOS as ordering and referring providers at minimum. And any services not meeting incident-to requirements must be billed under the NP or PA's own NPI. Incident-to billing is one of the most commonly audited areas in Medicare. If an audit finds that you billed incident-to services that did not meet all the requirements, you will owe the difference between the physician rate and the 85% rate for every claim, plus potential penalties. Most credentialing experts recommend enrolling NPs and PAs with their own Medicare provider numbers regardless of whether you plan to use incident-to billing. It gives you flexibility and eliminates compliance risk.