PYA Senior Manager Valerie Rock, along with Jana Kolarik from Foley & Lardner, presented “The Anatomy of Incident-To and Split/Shared Billing.” They discussed: - Compliant use of nurse practitioners and physician assistants. - The elements of incident-to and split/shared provider services. - Evaluation of manual guidance and the laws that impact interpretation of the provision. - Best practice application in common scenarios.

1. The Anatomy of Incident-To
and Split/Shared Billing
February 4-6, 2019
Jana Kolarik, Partner, Foley & Lardner LLP
Valerie G. Rock, Senior Manager, PYA

2. Items To Be Covered
1. Requirements of incident-to and split/shared
services
2. Manual guidance and laws that impact the
interpretation of the compliant use of Non-
Physician Practitioners (NPPs)
3. Best practice application in common
incident-to and split/shared service scenarios

3. INCIDENT-TO BILLING
The Anatomy of Incident-To and
Split/Shared Billing:

4. Interpreting Incident-To Compliance
• When Can a Physician Bill Incident To?
– Is the payer Medicare, Medicaid, or commercial?
– Is the service provided by clinical staff or physician-
level?
– Is scope of practice met?
– Is the patient new or established?
– Is the patient presenting with established problems,
or are any new problems addressed?
– Is the service integral/incidental?
– Where are the services provided?
– Which provider do I bill under?

5. Defining Incident To
• Incident to is commonly used to communicate
that NPPs are being billed under physicians’
billing numbers
• But many practitioners misinterpret or are
unaware of the billing and supervision
requirements
• Tip: Clarify the scenario before applying rules

6. Scope of Practice
• Payers only cover services rendered by
providers within their scope of practice that
are medically necessary
• Confirm the provider’s scope of practice is met
per state guidelines and supervising physician
delegation
• Must also meet standard of care

7. Which Payer Is Implicated?
• Assume that every payer has a different
definition of incident to or may not recognize
the provision
• Confirm current billing guidelines because
policies change as NPPs’ autonomy increases
• The Medicare incident-to guidance is the
common basis of the incident-to definition

8. Medicare Definition
“Incident to a physician’s professional services
means that the services or supplies are furnished as
an integral, although incidental, part of the
physician’s personal professional services in the
course of diagnosis or treatment of an injury or
illness.”
Source: Pub. 100-02 Medicare Benefit Policy Manual, Ch.
15, § 60.1 - Incident To Physician’s Professional Services

9. Commonly Furnished in Physicians’
Offices – Pub. 100-02, ch. 15, § 60.1A
• Services and supplies commonly furnished in
physicians’ offices are covered under the incident-to
provision
• Where supplies are clearly of a type a physician is not
expected to have on hand in his/her office or where
services are of a type not considered medically
appropriate to provide in the office setting, they would
not be covered under the incident-to provision
• To be covered, supplies must represent an expense to
the physician or legal entity billing for the services the
physician services or supplies

10. Direct Supervision - Pub. 100-02, ch. 15,
§ 60.1B
• Coverage of professional services and supplies in private practice
requires direct physician supervision of auxiliary personnel
• Auxiliary personnel – individual under the supervision of a
physician
– For example, an employee, leased employee, or independent
contractor of the physician, or of the legal entity that employs
or contracts with the physician
• The physician must have a relationship with the legal billing entity
that satisfies the reassignment rules
• Incident-to services or supplies must be an expense incurred by
the billing physician or legal entity
• The physician must be in the office suite and immediately
available to provide assistance and direction during the service

11. Who Is Providing the Service?
Auxiliary Personnel
• Clinical Staff
– Nurses
– Technicians
– Therapists
Non-Physician Practitioner
• Nurse Practitioner
• Clinical Nurse Specialist
• CRNA
• Certified Nurse Midwife (100%)
• Physician Assistant

12. NPP Services Rendered Incident To
The service is:
• Within NPPs’ scope of practice
• Performed under direct supervision of a physician in the
group practice
• An incidental and integral part of a services of a physician
in the group practice
• Subsequent to a professional service rendered by a
physician/NPP to initiate the course of treatment
• Followed by subsequent physician services at a frequency
representing continuing active participation in and
management of the course of treatment

13. Summary of Medicare Incident-To Billing
Guidelines
• Office only – not Inpatient or Outpatient, Emergency
Department, or Nursing Facility
• Established patient with established problem =
established plan of care
– Acute conditions are new, Chronic are established
• Not inclusive of NPP independent decision making
• Physician is on site (in the suite)
• Physician sees patient for initial visit to establish the
care plan and at a frequency showing involvement in
the care plan

14. Group Practice Supervision
• Any of the group practice’s physicians can
supervise services
• The service does not have to be supervised by
the ordering physician
• The supervising physician does not have to be
the same specialty
• NOTE: You must bill under a physician who is
present on site, which is not necessarily the
ordering physician

15. Medicare NPP Reimbursement
• Incident to met for NPP Service:
– Medicare reimburses 100% of the physician fee
schedule for claim billed under the supervising
physician on site
• Incident to not met for NPP Service:
– Medicare reimburses 85% of the physician fee
schedule for services which include independent
Medical Decision Making and billed under the NPP

16. Medicaid NPP Reimbursement
• Medicaid typically requires the provider
of service to bill for the service rendered
under his or her own number, commonly
reimbursed at 90%
–Some Medicaid payers do not recognize
incident-to rules or have different
requirements for supervision and billing

17. Homebound and Underserved
Provision
• Certain services may be covered and are
not held to the same direct supervision
standards when they meet qualifications
under 60.4
– Pub. 100-02 MBPM, Ch. 15, § 60.4 - Services
Incident To a Physician’s Service to Homebound
Patients Under General Physician Supervision

18. Therapy (PT/OT/ST) Provided Incident To
the Services of a Physician/NPP
• Therapy services are under their own benefit
category
• PTAs/OTAs work under the supervision of
PTs/OTs, not incident to, but billed under PT/OT
NPI
• If services incident to a Physician/NPP, must be
provided under direct supervision of the
Physician/NPP, can be billed under the
Physician/NPP
– Source: Pub 100-02 MBPM, Ch. 15, §230.4, 230.5

19. Medicare Administrative Contractors
(MACs)
• MACs provide additional guidance for
interpretation through articles and FAQs
• Healthcare entities should confirm the
interpretation for Medicare billing meets the
relevant MAC guidance

20. Commercial Payers
• Contact the payer to confirm whether NPPs can
be credentialed in the service area
• Review payer policies, manuals, and bulletins for
specific payer guidelines for NPP services:
credentialing, independent billing, supervision
requirements
• If the payer allows billing under the physician and
provides no further guidance:
– Follow the Medicare incident-to billing rules
– Follow state supervision and collaboration rules

21. Medicare NPP Independent
Services
• Office
– All services rendered without direct supervision
– New patient
– Established patient with New Problem/Condition
– Consultations
• Hospital
– NPP-only service, no physician E/M same date
– Critical Care

22. All Shared Method – Office
• NPP works up established patient, then physician follows
with review of key areas, establishes plan of care for new
problems, and renders final Medical Decision Making
• NPP dictates her portion of the note, then NPP dictates
physician’s portion as a scribe
• NPP signs attesting to both portions per role
• Physician signs approving scribed portion and as the
supervisor
• Service may be billed under the physician’s Medicare
billing number

23. SPLIT/SHARED SERVICE
The Anatomy of Incident-To and
Split/Shared Billing:

24. Medicare Shared Visit – Hospital
• NPP and physician document a portion of the
E/M service (same patient, same date of service)
– Bill under physician
• Note: Co-signature does not count
– Physician and NPP documentation must include some
E/M elements, at least one of the key elements:
history, exam, or medical decision making
– Example: “Saw patient and agree with above, heart
and lungs clear”

25. INCORRECT Common Practice in
Hospital Setting
• NPP sees patient first
• Physician follows, but does not document his
portion of the visit
• Physician may or may not co-sign
• All billed under physician
• This is incorrect
• Hospital visits are not subject to the incident-to
rules and must meet split/shared visit
requirements to be billed under the physician

26. All Shared Method – Hospital
• NPP works-up patient, physician follows with
review of key areas and final Medical Decision
Making
• NPP documents her portion of the note, then
NPP dictates physician’s portion as a scribe OR
the physician documents his or her portion of
the E/M

27. All Shared Method – Hospital
(cont.)
• NPP signs attesting to both portions per role
• Physician signs attesting to his or her
documentation
• Bill under the physician
• NOTE: If the physician does not see patient on
the same day or the physician does not
perform and document a portion of the E/M,
then you must bill under NPP

28. Who Is Required to Sign if the Service Is
Split/Shared or Incident To?*
Situation: Performed by: Signature Requirement:
Incident To Ancillary Staff Must be signed by supervising provider
(billing)
Incident To NPP May be signed by NPP or the supervising
physician
Split/Shared:
Office/Clinic Setting
NPP & Physician May be signed by the NPP or the
supervising physician; if this service is
billed under the physician’s NPI, the
billing physician MUST sign the record;
additionally, the documentation must
include a statement that the billing
provider had face-to-face contact with
the patient and performed a substantive
portion of the E/M visit (history, exam, or
MDM)
*NOTE: This guidance is from Palmetto GBA; each MAC may have different requirements, so
verify the requirements of the MAC in your state

29. Who Is Required to Sign if the Service Is
Split/Shared or Incident To?*
Situation: Performed by: Signature Requirement:
Split/Shared:
Hospital
Inpatient/Outpatient
/ED setting
NPP & Physician Must be signed by billing provider; if this
service is billed under the physician’s NPI,
the billing physician MUST sign the
record; additionally, the documentation
must include a statement that the billing
provider had face-to-face contact with
the patient and performed a substantive
portion of the E/M visit; (a substantive
portion of the E/M visit includes at least
one of the three key components--
history, exam, or medical decision
making)
*NOTE: This guidance is from Palmetto GBA; each MAC may have different requirements, so
verify the requirements of the MAC in your state

30. Productivity Considerations
• NPP productivity increases if the NPP is utilized to
maximize his or her skills and sees the patients
independently when possible
• Independent services decreases the per-visit average
collections; however, independent NPP services may
increase the NPP and physician total number of visits,
and can result in a net increase in revenue
• Overall productivity can decrease when the physician is
duplicating NPPs’ care in an attempt to achieve 100%
reimbursement; there is also a risk of noncompliance
under the billing rules that we just outlined

31. Easiest Method
• All patients are scheduled for all providers
• If an NPP sees a patient, for those payers which
credential NPPs, the NPP bills for the service
• For other payers, which do not credential NPPs and
while ensuring compliance with the billing rules, the
NPPs’ services are billed under supervising physician
• NPP notes the rendering provider and the supervisor
on the superbill or EHR fields for all services
• Exception: Hospital split/shared visit are billed under
physician, but you must ensure face-to-face by
physician takes place in such cases
• Supervising physician co-signs medical records per
scope of practice and state signature/supervision
requirements

32. 100% $ Option
• NPPs only see private payer and Medicare
established patients with established
problems
• NPPs turns patient over to physician if patient
presents with new problem

33. Medicare Resources
• Pub. 100-02 Medicare Benefit Policy Manual
Ch. 15, §§ 60 et seq., 230 et seq.
• Pub. 100-04 Medicare Claims Processing
Manual, Ch. 12, § 30.6 et seq.

34. Questions/Examples for Consideration
1. Can an NPP supervise another NPP?
2. If the physician is on the second floor, but the
NPP is performing a service on the first floor,
can we bill “incident to?”
3. Can any physician bill incident to within the
group (different specialty)? Example, the
patient established care with an orthopedic
surgeon, but was supervised by the pain
management physician

35. Questions?

36. Speakers
Jana Kolarik
Partner
Foley & Lardner LLP
Direct: 904.633.8915
Email: jkolarik@foley.com
Valerie Rock
Senior Manager
PYA
Direct: 404.266.9809 x2231
Email: vrock@pyapc.com