Currently, there are two ways in which to bill Medicare for Non-physician Providers (NPP) services: direct (under the NPP`s name and NPI) and incident to (under supervising physician`s name and NPI).

“Incident to” services are defined as those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.

“Incident to” billing is any billing that is provided incidental to the physician’s services by NPP, such as nurse practitioner (NP), physician assistant (PA), clinical nurse specialist, certified nurse-midwife etc.; the services are actually billed under the physician’s NPI number and not under NPP`s own number (direct billing). Medicare allows 100% of the Medicare fee schedule amount for “incident to” services and 85% for services billed under NPPs NPI. However, payments for certified nurse-midwife (CNM) services is made directly to CNM for their professional services, and for services furnished incident to their professional services at 100% of the physician fee schedule amount for the same service performed by a physician.

According to Medicare policy, In order to submit “incident to” billing the following criteria must be met:

1. The NPP must be a W-2 employee or leased employee with written contract.
2. Services must be provided in a physician’s office or clinic and be an integral part of the physician’s professional services (part of the physician’s treatment plan)
3. The physician must perform the initial service and have established a diagnosis and treatment plan.
4. The physician must see established patients for their first visits for any new problems.
5. The physician (or physician from the group) must be onsite when the NPP is seeing the patient within the office.
6. The physician must continue seeing the patient in such a way that it reflects ongoing involvement with the patient’s care.

Please note that simply co-signing NPPs note, briefly meeting the patient or co-visiting do not meet the requirements. Physician initial and new visits must be personal or face-to-face.

“Incident to” service is not appropriate in a hospital setting.

Unlike incident-to services, shared/split services may be reported in the ED, inpatient or outpatient department of the hospital. Shared services are E/M services that a physician and an NPP provide jointly. Both the physician and the NPP must provide face-to- face services to the patient on the same day and both must document their portion of the work. The level of the service is determined by combining elements in both notes to select the level of the service. If the only NPP sees the patient on that date, then the service must be reported under NPP`s NPI.

Incident-to billing requirements are not the same for private payers as Medicare (with exception of Aetna, which has adopted the same policy as Medicare). Private payers typically approach billing for NPPs one of two ways:

1. Enroll NPPs and have the practice bill under NPP`s own NPI and the group TIN
2. Do not enroll NPPs and have practices bill for services under the supervising physician`s name and NPI.

In many markets, commercial insurers, such as Aetna, Cigna, BCBS, 1199, UHC, Fidelis and Emblem Health enroll and credential NPPs, however not all commercial insurers follow Medicare “incident to” guidelines. As an example, BCBS requires NPPs who are eligible to receive their own NPI and who are recognized by the insurer must submit their claims directly to the insurer under their own NPI.

In most cases, if the payer doesn’t credential NPPs the claim would be billed under the physician’s NPI even if incident-to requirements have not been met.