In medical billing, there are situations where a service is provided by one provider but then billed under a different billing provider, called incident-to billing. There are very specific parameters that must be met in order for this type of billing situation to be compliant.
CMS sets the rules, which currently include:
- The services are rendered under the direct supervision of the physician, CP, NP CNM, CNS, or in the case of a physician directed clinic, the Physician Assistant (PA).
- The services are furnished as an integral, although incidental, part of the physician's, CP's, NP's, CNM's or CNS's professional services in the course of the diagnosis or treatment of an injury or illness.
- Billing 'incident to' the physician, the physician must initiate treatment and see the patient at a frequency that reflects his/her active involvement in the patient's case. This includes both new patients and established patients being seen for new problems. The claims are then billed under the physician's NPI.
- Billing 'incident to' the CP, NP, CNM, CNS or PA, the non-physician practitioners may initiate treatment and see the patient at a frequency that reflects his/her active involvement in the patient's case. The claims are then billed under the non-physician practitioner's NPI.
Please note, there are specific scenarios where this type of billing would not be compliant, even if the above criteria is met. Please research all state laws/rules, as well as those of your local MAC or insurance payer prior to billing in this manner.