While CMS rules regarding billing for physician extenders, including Physician Assistants (PA) and Nurse Practitioners (NP) and other Non-Physician Providers (NPP), have been published and consistent for several years, it is common to find practices that do not know or follow them. The purpose of this letter is to simplify the rules to help keep practices in compliance with CMS guidelines. This letter specifically covers rules for billing for an extender that is enrolled with CMS versus not enrolled, and when it’s appropriate to bill the extender as “Incident to”.
WHO IS RESPONSIBLE?
- Once enrolled in the Medicare program as a provider, the responsibility of understanding and abiding by the rules and regulations falls on your shoulders.
- The provider who performs the service on the patient and the billing provider are both responsible for the compliance of the claims they submit. Most of the time the performing provider and the billing provider are the same. But when a practice takes on an extender, there are more instances when the performing and billing providers may not be the same.
- As an enrolled provider, you are responsible for finding out what the rules are and making sure they are followed.
- Ignorance of the law is no excuse.
WHAT ARE THE BILLING RULES FOR PHYSICIAN EXTENDERS THAT ARE ENROLLED WITH CMS?
- Enrolled extender services are billed under the extender’s name as both the performing and billing provider.
- Enrolled extender services are reimbursed by CMS at 85% of the CMS fee schedule.
WHAT CAN A PHYSICIAN EXTENDER THAT IS NOT ENROLLED WITH CMS DO?
- Perform services under direct supervision as an “Incident to” provider
- Serve as a “scribe” on behalf of the performing/billing provider
WHAT DOES “INCIDENT TO” MEAN?
- CMS defines “Incident to” as those services that are furnished “Incident to” physician professional services in the physician’s office.
- These services are billed as Part B services to Medicare as if you personally provided the service and are paid at 100% of the CMS physician fee schedule.
HOW DOES AN EXTENDER QUALIFY AS “INCIDENT TO”?
- The Physician must personally perform the patient’s initial service and must remain actively involved in patient’s normal course of treatment.
- An extender’s services must be part of the patient’s normal course of treatment.
- The Physician does not have to be physically present in the patient’s treatment room while the services are provided, but must provide “direct supervision,” which means the Physician must be present in the office suite to render assistance, if necessary.
- The medical record should document the essential requirements for Incident-to service.
“INCIDENT TO” RULES DIFFER DEPENDING UPON LOCATION:
- Physician Office – In a physician office, “Incident to” services must be provided by someone the enrolled physician or enrolled extender directly supervises, and who represents a direct financial expense to the practice. The supervising provider does not have to be physically present in the room where the patient is receiving services, but must be present in the immediate office suite to render assistance if needed. In a group practice, any enrolled provider that is a member of the group may be present in the office to supervise. The supervising provider is also the billing provider.
- Hospital – Although there are certain specific exceptions, “Incident to” services are generally not permitted in a hospital setting.
CAN ENROLLED EXTENDERS ALSO SUPERVISE INCIDENT-TO PROVIDERS?
- Yes, “Incident to” billing is permitted if the supervising provider is a properly enrolled extender that bills directly to Medicare.
- Keep in mind that if “Incident to” services are provided, the same rules must be followed and the reimbursement rate remains at 85% of CMS allowable.
WHAT HAPPENS WHEN AN EXTENDER SERVES AS A “SCRIBE”?
- Occasionally physicians choose to use non-enrolled extenders as “scribes” meaning that the extender documents the encounter in the practice’s EHR on behalf of the performing/billing provider.
- While this is permitted, the encounter note must clearly indicate that the extender served as the “scribe” for the encounter.
- The extender should not be listed as either the providing or billing provider and should not sign the note.
BILLING REQUIREMENTS – FAQs
1. Question: Are you required to enter the staff member’s name in the Medicare narrative section of the claim (Box 19)?
- Answer: No. Including the name of the staff performing the services is not a requirement. It is optional. What is required is the documentation must indicate who performed the service and who provided the direct supervision.
2. Question: Is a modifier required to indicate “Incident to”?
3. Question: Can an established patient with a new condition be seen by an extender and billed as “Incident to” service?
- Answer: No. “Incident to” billing is not appropriate for new conditions.
4. Question: I performed the initial treatment plan but, at a later date, another provider within the group practice was in the office and supervised the “Incident to” services for my patient. Can the claim still be billed under my name?
- Answer: No. The claim must be billed under the supervising physician’s name.
5. Question: Can an exacerbation of a chronic condition be billed “Incident to”?
- Answer: Yes, as this is not considered to be a new condition, even if the extender changes or prescribes a new prescription. However, if the changes in the prescription do change the overall plan of care, it will no longer meet the “Incident to” requirements.
- Ensure all enrolled providers in your practice, whether physicians or extenders, are properly informed of CMS rules regarding physician extenders.
- An educated, qualified staff will help your practice succeed.
- Enrolled extender services are billed under the extender’s name as the performing and billing provider and reimbursed by CMS at 85% of physician fee schedule.
- “Incident to” services are only permitted if the patient is established and the services are part of the patient’s normal course of treatment
- Incident-to services are billed with the extender as the performing provider and the supervising provider as the billing provider and reimbursed by CMS at 100% of physician fee schedule.
- The billing provider must remain actively involved in the patient’s course of treatment.
- Direct supervision is required for “Incident to” providers, which means the supervising provider must be present in the office suite to render assistance if necessary.
- The note in the medical record should clearly indicate which provider performed the services and which, if any, provider supervised the services. Additionally, the note should indicate if an extender served as a scribe.
- If Incident-to services were performed, clearly document the essential requirements.
Medicare Benefit Policy Manual, Chapter 15 Medicare Benefit Policy Manual Chapter 15