The 5 Basic Requirements of Incident To

Understanding incident-to can be stressful. According to an MLN Matters article, number SE0441, “To qualify as “incident to,” services must be part of your patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment.”

There are five basic requirements that must be met to bill the service under the physician as incident-to:

1. The physician must personally perform the initial service and remain actively involved in the patient’s care.
2. The physician must be in the office suite when the services are performed.
3. Generally, services must be performed in the office (there are some exceptions).
4. Must represent an expense to the physician.
5. And of course, they must be medically necessary.

A perfect incident-to scenario might look like this: A patient sees her primary care MD at his office. She has diabetes and requires weekly visits. Instead of seeing the MD every week, she will see the nurse practitioner in the same office. The MD is in the office area when the patient is seen, and the NP only manages the diabetes. The physician will see the patient personally at least once per month. In this case, the charges for the visits with the nurse practitioner could be billed under the MD.

Doesn’t sound so bad, does it? Mid-level provider visits are only paid at 85% of the rate that physician services are, so it’s understandable that practices want to recoup any funds they can.

However, numerous problems come to play when practices start billing charges under physicians instead of billing them directly under the provider rendering the service.

Download our free eBrief, The Essential Elements of Incident-To, written by superstar auditor Lori Cox, for a more in-depth look at incident-to. You’ll get incident-to requirements, examples of what not to do, and tips on How to Audit Incident-To.