What Is Incident-To Billing?
Incident-to billing lets a practice bill certain services provided by a nurse practitioner or physician assistant under a physician’s NPI, at the full physician fee schedule rate instead of the reduced NPP rate. It is valuable, and it is also one of the most commonly misapplied Medicare rules. Here is how it works and what it requires.
What incident-to billing means
Incident-to is a Medicare billing provision. When a non-physician practitioner (NPP), such as an NP or PA, provides a service that is an integral part of the physician’s care, the practice can bill it under the supervising physician’s NPI. The benefit is reimbursement: NPP services billed under their own NPI are paid at about 85% of the fee schedule, while a qualifying incident-to service is paid at 100%.
The requirements (all must be met)
- Established patient, established problem. Incident-to does not apply to a new patient or to a new problem for an existing patient. The physician must have seen the patient first and set the plan of care.
- An established plan of care. The NPP is carrying out a plan the physician already created, not creating a new one.
- Direct supervision. A physician (it does not have to be the same one) must be physically present in the office suite and immediately available while the service is provided. Not on call, and not in a different building.
- Physician involvement in care. The physician must remain actively involved in the patient’s ongoing treatment.
- Office setting. Incident-to applies in a non-facility office setting, not in a hospital or facility.
Where incident-to does NOT apply
It does not apply to new patients, to new problems, when no physician is present in the suite, or in a hospital or facility. In the hospital, the relevant concept is split (or shared) billing, which has its own separate rules. Treating a facility encounter as incident-to is a frequent compliance error.
Why the rule matters
The stakes run both ways. Billing incident-to when the requirements are met captures the full 100% payment a practice is entitled to. Billing incident-to when they are not met is an overpayment that can trigger a recoupment or audit finding. Because the requirements hinge on facts that change visit to visit (new vs established problem, whether a physician was in the suite), documentation is everything.
How to stay compliant
The practical safeguards are clear documentation of the physician’s initial visit and plan of care, a record of which physician was present and available during each incident-to visit, and a coder who checks each encounter against the requirements before it is billed under the physician. That is exactly the kind of check our certified coding team runs. If you are unsure whether your NPP visits are billed correctly, a free revenue analysis will review it.
FAQs
What is incident-to billing?
Incident-to billing is a Medicare rule that lets a practice bill certain NPP services (from an NP or PA) under the supervising physician’s NPI, paid at 100% of the fee schedule instead of the reduced NPP rate, when specific requirements are met.
What are the requirements for incident-to billing?
An established patient with an established problem, an existing physician plan of care, direct supervision (a physician physically present in the office suite), ongoing physician involvement, and a non-facility office setting. All must be met.
Can incident-to be used for a new patient?
No. Incident-to does not apply to new patients or to a new problem for an existing patient. In those cases the service is billed under the NPP’s own NPI.
What is the difference between incident-to and split/shared billing?
Incident-to applies in the office setting under direct physician supervision. Split or shared billing applies in the facility or hospital setting when a physician and an NPP both contribute to a visit, and it follows its own separate rules.