Terry A. Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM
Incident to a physician’s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness. This comes directly from the Medicare Benefit Policy Manual Chapter 15, section 60.1.
The important distinction here, for this month’s “audit tip,” is supervision, when we discuss “services”, and not just evaluation and management (office visits).
Now, to be clear, services and supplies commonly furnished in physicians’ offices are covered under the “incident to” provision. However, incidental supplies, or what is typically part of doing business, in a physician’s practice, such as gauze, exam-table paper, ointments, bandages, and/or oxygen used in clinic, must be included in the physician’ bill for the E/M and not separately reported.
To be covered and billed separately, supplies, including drugs, diagnostic testing, and biologicals, must represent an expense to the physician or legal entity billing for the services or supplies. For example, when a patient purchases a drug and the physician administers it, the cost of the drug is not covered. However, the administration of the drug, regardless of the source, is a service that represents an expense to the physician. Therefore, administration of the drug is payable if the drug would have been covered if the physician purchased it. The “Direct Personal Supervision Coverage” also applies to incident to services and supplies, but may be limited to situations in which there is direct physician supervision of auxiliary personnel (i.e., physician private practice). (60.1.B)
Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician. There does have to be an employment relationship, because “you can’t pass along an expense to a patient that the billing provider didn’t incur.”
A question has come up recently, on Physician Assistants: “Can they provide independent x-ray interpretation, under the “incident to” rule? The answer, found in MBPM Chapter, 15, 60.2 §§190, discusses this.
“Services of Nonphysician Personnel Furnished Incident To Physician’s Services ordinarily performed by the physician such as minor surgery, setting casts or simple fractures, reading x-rays, and other activities that involve evaluation or treatment of a patient’s condition, ……. to be covered as incident to the services of a physician, the services must meet all of the requirements for coverage specified in §§60 through 60.1. For example, the services must be an integral, although incidental, part of the physician’s personal, professional services, and they must be performed under the physician’s direct supervision. A nonphysician practitioner such as a physician assistant or a nurse practitioner may be licensed under State law to perform a specific medical procedure and may be able (see §§190 or 200, respectively) to perform the procedure without physician supervision and have the service separately covered and paid for by Medicare as a physician assistant’s or nurse practitioner’s service. However, in order to have that same service covered as incident to the services of a physician, it must be performed under the direct supervision of the physician as an integral part of the physician’s personal in-office service.”
So the point, isn’t whether the PA can provide the service, that is a State Licensure, and Scope of practice question, which needs to be answered first by the practice. The question here is, whether these services can be billed incident to under the physician, in order to receive the 100% allowable benefit. This is a reimbursement question as well as a supervision question.
As explained in §60.1, this means that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary. So even though taking an x-ray is under a “general supervision” guideline for a diagnostic test, if a PA or NP is the one doing the interpretation if allowed in their state, and trying to bill this out under the physician incident to, the incident to rules have to be met, which means, the physician as to be in clinic at the time the service was provided.
I also wanted to remind those that are auditing or utilizing incident-to-rules in their practices, that there is also a definition of a “physician-directed clinic.” This one rule definition may surprise you. I mentioned it to a provider client during a recent audit, and they said, “uh oh, we did not know that part of the published rules.”
So, as stated in Chapter 15, 60.3 – Incident To Physician’s Services in Clinic (Rev. 1, 10-01-03) B3-2050.3 Services and supplies incident to a physician’s service in a physician-directed clinic or group association are generally the same as those described above. A physician-directed clinic is one where: 1. A physician (or a number of physicians) is present to perform medical (rather than administrative) services at all times the clinic is open; 2. Each patient is under the care of a clinic physician; and 3. The nonphysician services are under medical supervision.
This is an important distinction as I have seen many practices park a physician in a practice to catch up on his or her charting, or to “manage” the clinic, but they are not treating providers. This is not considered incident to direct supervision, as per the statute.
Physicians who are there in a clinical capacity, qualify for the supervision role. If it is a multiple physician-led clinic, of the same specialty, any physician can be the “supervising physician” that day, and it does not need to be the patient’s physician if they are not available.
Always, read the fine print when looking up published guidance, and read the rules in their entirety so as not to miss important stipulations such as this one.
Reference: Medicare Benefit Policy Manual Chapter 15 section 60
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf
What to do next…
- If you or your organization need help with audits or provider education, contact NAMAS at (877) 418-5564 or via email at namas@namas.co.
- Take a look at more information and tips on the NAMAS YouTube channel and the NAMAS blog
