April 26, 2024 | Sean M. Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC
The perennial inquiry into the scope of services that nurses and ancillary support staff may offer under physician supervision remains a frequent topic of discussion. Furthermore, I frequently encounter situations where the concept of “incident-to” care is central to the controversy. In these cases, there are individuals who profess to be “experts” and offer opinions despite lacking appropriate qualifications. I have heard some say incident-to is simple and straightforward, but the question is, if it’s so simple, why are there so many cases of providers being prosecuted for getting it wrong? Why have CMS Administrators gone on records and stated that they will continue to provide clarifications and updates to their policies?
The fact is, this is not a simple and straightforward billing provision, it is among the most complex and difficult to get right because of all the “what-ifs” … However, there services that can be performed by nurses and ancillary staff members and they’re able to be reimbursed under the supervising provider’s National Provider Number (NPI). Under direct supervision of a physician, nurses and ancillary staff can provide a wide range of services, depending on their training, qualifications, and the policies of the healthcare organization.
Some of the services they may provide include:
- Patient assessment: Nurses and ancillary staff can assist in conducting initial patient assessments, including taking vital signs, recording medical history, and assessing symptoms.
- Medication administration: They can administer medications as prescribed by the physician, ensuring proper dosage and timing.
- Basic medical procedures: This might include wound care, injections, catheterization, and other basic medical procedures as directed by the physician.
- Patient education: They can provide education to patients and their families about medications, treatments, and self-care practices.
- Monitoring patients: Nurses and ancillary staff can monitor patients’ condition and report any changes to the physician, such as changes in vital signs or symptoms.
- Assisting with procedures: They can assist physicians during medical procedures, surgeries, or examinations.
- Documentation: They are responsible for accurately documenting patient information, including assessments, treatments, and medications administered.
- Providing support: They offer emotional support to patients and their families, answering questions and addressing concerns.
- Rehabilitation support: In some cases, nurses and ancillary staff may assist in providing rehabilitation services under the direction of a physician or physical therapist.
- Emergency response: They can assist in emergency situations, following established protocols and providing support until further medical assistance arrives.
It’s important to note that the exact scope of practice for nurses and ancillary staff under direct supervision can vary depending on local regulations, facility policies, and the specific instructions provided by the supervising physician. Make sure to always consult the State Nurse Practice Act where your practice resides to ensure compliance.
Incident-to Services
“Incident-to” services refer to medical services provided by non-physician healthcare professionals (such as nurse practitioners, physician assistants, or clinical nurse specialists) under the direct supervision of a physician. These services are typically billed under the physician’s National Provider Identifier (NPI) number and are reimbursed at the physician’s rate rather than the lower rate typically associated with services provided solely by non-physician practitioners.
The key requirements for billing incident-to services include:
- Direct supervision: The supervising physician must directly supervise the non-physician provider’s services. This means the physician must be present in the office suite and immediately available to provide assistance and direction as needed.
- Established plan of care: The services provided by the non-physician practitioner must be part of a patient’s established plan of care that was initiated by the supervising physician during an earlier visit.
- Services within scope of practice: The services provided by the non-physician practitioner must be within their scope of practice and consistent with the state laws and regulations governing their practice.
- Documentation: Proper documentation of the incident-to service must be maintained in the patient’s medical record, including the supervising physician’s involvement and the services provided by the non-physician practitioner.
Common examples of incident-to services include routine office visits, follow-up visits, and certain minor procedures performed by non-physician practitioners under the supervision of a physician. However, it’s important for healthcare providers to be aware of specific regulations and guidelines governing incident-to billing in their respective jurisdictions, as these may vary.
For complete guidance on Incident-to Services refer to The Medicare Benefit Policy Manual, Chapter 15, Section 60.1 and beyond (bp102c15.pdf (cms.gov)) .
Download the Incident-to Reference Guide from NAMAS
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