26 Apr Medical Billing and “Incident to” Procedures
Medical billing for “incident to” services can be tricky, as there are certain criteria that must be met in order to do this successfully. Incident to services may be either supplies or services provided to a patient in the diagnosis or treatment of an illness or injury that are integral to the treatment but incidental. They are part of a medical doctor’s or healthcare worker’s personal professional services.
Instances for Incident To
Billing for incident to services applies to Medicare payments and, depending upon the state, Medicaid payments. It may also pertain to some commercial insurance providers, depending upon the company and its policies. In the realm of the bottom line, many healthcare practices will bill incident to. If the visit and procedures followed conform to all rules governing this type of payment, then 100% of the amount allowed for a Medicare physician may be reimbursed.
Many times a healthcare practice will have patients see an advanced practice clinician, such as a nurse practitioner or physician’s assistant; through Medicare, these personnel are allowed 85% of the physician’s reimbursement. However a practice would like to collect 100%, and in order to do so they will bill Medicare for 100% of the allowable physician’s fee, increasing their profit margin. However, in order to do this there are specific criteria that must be met.
The Rules for Incident To Reimbursement
It’s important to note, that billing for incident to services without knowing the law or in violation of such can lead to an investigation for fraud. Therefore, if there is any question concerning this billing practice, consult your medical billing and coding professional or the appropriate insurance provider.
According to Medicare, the following rules apply:
• The physician must perform the initial visit for a specific condition.
• After that, the patient may see the advanced practice clinician, and they do not need to see the physician.
• However, there must have been a direct, personal, professional service provided by the physician in order to start the course of treatment, which is incidental and is being performed by the advanced practice clinician.
• During incident to services, the physician must be physically present in the same office suite and be immediately available to provide assistance if necessary.
• The physician must be actively involved in the ongoing care of the patient.
Being actively involved includes the physician rendering succeeding services at a frequency that reflects participation in treatment and management of the patient’s complaint.
• The advanced practice clinician must be an employee of the physician.
If all of the above criteria are met, then incident to billing may be implemented.
Conforming to the Law
In billing for incident to services, the criteria for seeking 100% reimbursement from Medicare is extensive. Often, the full list of the regulations summarized and explained in this blog cannot be met. Medical billing and coding professionals are the best resource for questions regarding incident to.
If you would like more information concerning safe billing practices, incident to billing, and other aspects of billing and coding please feel free to contact Medical Practice Management Resources, Inc. We are ready to answer your questions and help you.