Be ‘Double the Doc’

How to bill incident-to -- and guidelines for when you can and can't

Medicare reimburses non-physician providers - physician assistants and nurse practitioners, for example - at a lower rate than physicians. However, practices can bill the services at the full physician level, provided those services were delivered “incident-to” a physician’s treatment.

In short, incident-to billing can give practices a “double whammy,” says R. Todd Welter, a healthcare billing consultant and principal with R.T. Welter & Associates in Denver. “You can actually be double the doc.”

In other words, if physicians see all new patients, and non-physician practitioners take care of follow-up visits but bill at physician rates, “you can go through double the patients” and make good money, says Welter.

Too often, “people lose out on a really good way to bill and see more patients in the same amount of time because they don’t understand the rules,” Welter adds.

And therein lies the rub. Misunderstanding the rules may mean more than potential lost revenue; it may also mean a visit from Uncle Sam.

“[Incident-to billing] is getting increasing attention not only from Medicare but from the Office of the Inspector General (OIG). We need to make sure, from a compliance perspective, that we have a very good handle on the rules,” warns Dennis K. Grindle, an accountant and partner in healthcare consulting with Seim, Johnson, Sestak & Quist in Omaha, Neb. “HCFA is very serious about the strictness of the incident-to criteria. We need to make sure that care meets the criteria, and that we can prove it. It’s not always easy.”

In an audioconference on non-physician provider billing with the Medical Group Management Association (MGMA), Grindle suggested some practices should simply bill at the lower rate, rather than search for ways to bill incident-to. Still, he adds, billing incident-to is perfectly legal, as long as all criteria are met.

How to judge

Managers who want to know whether a specific service can be billed incident-to, suggests Grindle, should first make sure the service provided falls under the provider’s scope of practice and state licensure rules. If a physician assistant is not legally allowed to do the procedure under question, you are already in trouble.

State rules have precedence over federal rules when it comes to saying which kind of providers cannot perform which services; state rules form the foundation of incident-to, Grindle says.

“If the state says these are services that can’t be provided by this practitioner, Medicare is certainly going to bow to that authority,” he says, adding that it doesn’t work the other way around, however: If a state says it’s OK for a practitioner to provide a service, Medicare may not agree.

Second, managers should confirm that the service is provided under Medicare Part B, the only program relevant for incident-to billing.

Third, to be covered under incident-to, the service must be provided as “an integral, although incidental, part of the physician’s professional service,” as Grindle puts it. In other words, the care must be part of a course of treatment established by the physician.

For example, during an initial visit with a patient, a physician diagnoses the problem and prescribes a series of injections over the course of several weeks. When the patient returns a week later for an injection, he can go straight to the non-physician practitioner who can administer the injection and bill the service as incident-to - assuming the care is part of the physician’s service.

When to be there

Fourth, the non-physician can only perform services - and bill them as incident-to - if the treatment is “furnished under the physician’s direct personal supervision,” in HCFA’s language. That does not mean the physician needs to be hovering over the shoulder of the nurse practitioner. It does mean, however, that the physician needs to be available.

ldquo;Medicare feels very strongly that the physician needs to be on-site in case the course of treatment needs to change. The physician must be there to intervene,” Grindle explains.

Of course, “on-site” has only vague meaning in a world of integrated systems and acres-wide health campuses. But managers should set reasonable limits.

“[The bottom line is that] the supervising physician needs to be on the same floor or within a reasonable distance. They have to be accessible if someone needs help,” Welter summarizes.

The physician can’t be in the hospital next door on rounds or on the golf course with his cell phone handy. If the original physician isn’t around, but another physician is, it is wise to bill the service incident-to the physician who actually saw the patient on the day the treatment was rendered, Grindle advises.

The fifth criteria that must be met to bill incident-to is that the service is usually included in the physician’s bill.

Sixth, the incident-to service has to be delivered in a physician’s office, the patient’s home, or an institutional office leased by the physician and explicitly set out as the physician’s office.

“This is an extremely, extremely important point,” Grindle feels. If treatment was given anywhere but these settings, you can’t bill incident-to.

Finally, the service must be provided by the physician or by an individual who qualifies as an employee of the physician. That means a W-2 relationship or a leased employee, Grindle explains.

It does not mean independent contractor/mid-level provider relationships. Such situations can prove problematic. Grindle often sees rural practices that bring in a specialist - say, an orthopedic surgeon - from the nearest city once or twice a month. All the physicians in the rural group are employees of that group, whereas the visiting surgeon is an employee of his city-based group. So, when he wants a non-physician practitioner to give him a little help, that help can’t be billed as incident-to the work of the specialist. The employer/employee relationship is not being satisfied.

“I’m not a big fan of independent contractor relationships,” Grindle summarizes.

What to watch for

Apart from meeting the incident-to criteria, practice leaders should look out for these common mistakes, Welter warns.

  • Not using incident-to at all. Although the rules need some attention, incident-to billing can be too valuable to a practice to simply be ignored.

  • Not having the physician co-sign the note. Bills need the signature of both the mid-level provider and the supervising physician. Otherwise, “if you get audited, it looks like the physician assistant is billing an office visit charge but the bill has the doctor’s name on it. That looks like fraud,” Welter says.

  • Not training and auditing non-physician practitioners. A mid-level provider may be legally billing a service incident-to, but there is still fraud being committed if he or she uses the wrong code. Practices tend to teach physicians about coding and ignore other providers, Welter comments. They also exclude non-physician practitioner bills from audits, making it less likely that mistakes will be caught.

If you discover a mistake in the way you bill incident-to, “you just need to stop making it,” Welter suggests. Although it’s important to judge things on a case-by-case basis there is usually “no reason to make a big fuss about it” by calling Medicare, Welter adds. If you’ve been billing incident-to when the physician is not present, re-do the schedule so that he is - and start getting the most bang for your efforts - legally.

Pamela L. Moore, senior editor, practice management, with Physicians Practice, can be reached at

This article originally appeared in the March/April 2001 issue of Physicans Practice.