“Incident to”….What Does That Mean?

Many terms used in the “rules” for medical billing seem like they belong more in a law book, than a billing guide.

 That is how I start to feel when reading about billing “Services and Supplies Furnished Incident to a Physician’s/NPP’s Professional Service.”

 CMS ManualFor my enlightenment and hopefully yours, I have attempted to glean the basics from about 10 pages in section 60 of the Medicare Claims Processing Manual, Chapter 15 “Covered  Medical and Other Health Services”.

 what is incident toLet’s start with an easy concept: An incident to service or supply is a service or supply not covered in one of the other benefit categories.  The other benefit categories are:

·         Drugs and Biologicals

·         Sleep Disorder Clinics

·         Diagnostic X-Ray, Diagnostic Laboratory and Other Diagnostic Tests

·         X-Ray, Radium and Radioactive Isotope Therapy

·         Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations

·         Durable Medical Equipment

·         Prosthetic Devices

·         Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes

·         Therapeutic Shoes for Individuals with Diabetes

·         Dental Services

·         Clinical Psychologist Services

·         Clinical Social Worker (CSW) Services

·         Nurse Midwife (CNM) Services

·         Physician Assistant (PA) Services

·         Nurse Practitioner (NP) Services

·         Clinical Nurse Specialist (CNS) Services

·         Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech Language Pathology Services) Under Medical Insurance

 integral to professional serviceTo see the details of services that fall into these benefit categories, you can access the Medicare Claims Processing Manual, Chapter 15 by clicking here.

Well, now that has narrowed things down quite a bit. Let’s look at the next part that makes a service or supply “incident to”.  It is considered:

·         Integral to the performance of the *physician’s professional service

·         Commonly rendered without a separate *physician fee and furnished in *physician’s offices or clinics

medical supplies Supplies commonly considered “incident to”: gauze, ointments, bandages, oxygen

·         Furnished by the physician or by **auxiliary personnel under the *physician’s *** direct supervision

auxiliary personnel Services of auxiliary personnel are considered incidental to a physician service when they assist in rendering the service, and the charge is included in the physician’s bill.  This also applies if auxiliary personnel perform a subsequent service as part of a course of treatment initiated by the supervising physician.

*Physician: includes physician, physician assistant, nurse practitioner, clinical nurse specialist, nurse midwife, clinical psychologist.

**Auxillary Personnel:  personnel whether employee, leased employee, or independent contractor that acts under the supervision of a physician.  May include services by Non-physican practitioners: certified nurse midwives, clinical phychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialitsts.

***Direct supervision: the physican must be present in the office suite and immediately available to assist the auxiliary personnel in preforming the service.

homebound patientSpecial Rules for Homebound Patients and Incident to Services

In medically underserved areas the shortage of medical personnel to provide certain medical services to homebound patients allows for an exception to the direct supervision rule.  In these circumstances, nurses, technicians and other physician extenders may provide these services under the *general supervision requirement instead of the direct physician supervision requirement.

*General supervision means that the physician is not physically present at the place of residence when the service is performed, but is under his/her overall supervision and control.

auxiliary personnelServices that can be covered incident to under general supervision: Injections, venipuncture, EKGs, therapeutic exercises, insertion and irrigation of sterile catheter, changing of catheters and collection of catheterized specimen for urinalysis and culture, dressing changes, replacement and/or insertion of nasogastric tubes, removal of fecal impaction, sputum collection for stain and cultures, paraffin bath therapy for hands and/or feet, teaching and training the patient for care of colostomy, ileostomy, or tracheostomy, testing urine, care of diabetic feet and blood pressure monitoring.

The specific criteria for “Service Incident to a Physician’s Service to Homebound Patients under General Physicians Supervision”:

·         The patient is *homebound

*Homebound: a patient is considered homebound if they possess a normal inability to leave home, such that leaving the home would require a considerable and taxing effort.

·         The service is an integral part of the physician’s service to the patient and done under general physician supervision. 

·         The physician orders the service, maintains contact with the employee and upholds all responsibility for the service.

·         The physician or clinic has an associated expense and their bill includes the fee for the rendered procedure.

·         Any service performed is medically necessary and reasonable and unavailable by a Home Health Agency.