In-Office Requirement for Incident-To

February 1, 2008

I have searched and searched for a rule that states that the “physician must be in the office suite while the nonphysician provider is practicing.” Is this a guideline from Medicare and only for Medicare patients or is this specified elsewhere and applies to all NP services regardless of insurance carrier? Often we hear the rhetoric that we don’t have to accommodate these guidelines when it is for commercial carriers only. I’d really appreciate clarification on the statement and the supporting documentation for it.

Question: I have searched and searched for a rule that states that the “physician must be in the office suite while the nonphysician provider is practicing.” Is this a guideline from Medicare and only for Medicare patients or is this specified elsewhere and applies to all NP services regardless of insurance carrier? Often we hear the rhetoric that we don’t have to accommodate these guidelines when it is for commercial carriers only. I’d really appreciate clarification on the statement and the supporting documentation for it.

Answer: This language is from the Medicare Carrier’s Manual:

“Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”

See Section 2050 of the carrier’s manual or follow this link to access it online. Note that “incident-to” billing is a Medicare-only concept. While some commercial payers may follow its lead, others may not. Many don’t have any real policy on incident-to. The only way to know what they expect is to ask each carrier.

Of course, states and regulatory boards will have their own supervision requirements, separate from the incident-to billing issues. Check with these as well.