What is Incident-to Billing and How Can You Claim It

Physicians and hospitalists can get paid from incident-to-billing to improve revenue collections in their practice by billing the nurse visit under the physician’s supervision. But how do you ensure that you are compliant with incident-to-billing guidelines? Let’s find out.

Incident-to-Billing Definition

Incident-to-billing is a provision under Medicare, where a medical practitioner can bill 100 percent of their charges fee, even when the medical service is not directly provided by them in-person. The doctor can have his or her staff which should be a registered nurse practitioner (NP), registered nurse (RN), or PA (physician assistant) to attend to the follow-up patients.

Incident-to-billing is also known as shared billing if the patient is seen in the hospital by pa under the physician’s supervision

Incident-to-Billing Preconditions

To invoice under the incident-to-billing provision, you must ensure the following:

1. Credentials of Person Appointed: The person performing the medical service on your behalf must be a registered nurse practitioner (NP), registered nurse (RN), PA (physician assistant), or a doctor employed under the same the same medical entity.
2. Place of Service: The medical check-up should be performed in your place of service 11. The Centres for Medicare and Medicaid Services defines place of service 11 as ‘Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.’ If you don’t do a place of service 11, you cannot claim incident to billing.
3. Only Follow-Up Visits: Incident-to-billing can be done only for a follow-up visit. For instance, if the physician has prescribed a review of the blood pressure in three days, and the checks on the follow-up visit are performed by the NP or PA, without the physician being in attendance, the billing can be done at the physician’s fee. However, if during the follow-up visit, the patient reports a new condition and is attended to by the NP, then the new condition cannot be billed as incident-to-billing.
4. Plan of care: The physician claiming the incident-to-billing has certified the plan of care for the patient. Note that these regulations vary across states and Medicare contractors. For example, Cahaba has a rule that every doctor who does incident to billing must also co-sign the follow-up documents.
5. Level of Supervision: You must meet the conditions for supervision to claim incident-to-billing. There can be three levels of supervision:

• General supervision: The primary care doctor is not present at the place of service during the patient’s follow-up visit. In some states and Medicare providers, this scenario is not billable under incident-to-billing.
• Direct supervision: Doctor is also present at the premises although he may not directly attend to the follow-up patient. This is billable under incident-to-billing.
• Personal supervision: The doctor is present in the room while the nurse sees the patient. In this case, as well, you can bill 100 percent of the physicians s fee schedule.

Medical practitioners and hospitals in violation of the incident-to-billing payer rules can be subject to Medicare audits and prosecuted for billing fraud. As per an article published on June 28, 2018, in the Tampa Bay Business Journal, four physicians from Tampa Bay (along with nine other individuals) are facing charges more than $2 billion dollars in false medical billings under the Medicare, Medicaid, and Tricare healthcare programs. It is indeed heartbreaking to see entrusted members of the medical community betray the trust of vulnerable patients and cheat the taxpayers.

To avoid violating healthcare regulations in your medical practice, it’s imperative that your billing staff understand the incident-to-billing guidelines. But staying on top of changes in claim procedures, guidelines, and billing technologies can be challenging for a healthcare practice and even larger hospitals with trained billing staff.

That’s where the PracticeForces team, with more than eighteen years of proven expertise in healthcare billing service and revenue management, can help. Contact us today to know more about how we can improve the way you collect payments and service clients.

Check out another article with tips to boost patient collections and payments.