Over the years, the incident has remained a prominent topic of discussion, while shared care has emerged as a relatively new billing opportunity provided by CMS. Many physician offices find themselves perplexed about the appropriate billing methods for these services and how they distinguish from each other. The recent alterations made by CMS to their shared care policy have only added to the existing confusion. It is crucial to minimize the likelihood of audits, paybacks, and potential future reimbursement delays by ensuring accurate billing practices. Inaccurate billing discovered during a payer audit can lead to subsequent pre and post-payment reviews, further exacerbating the reimbursement process. To address these concerns and promote proper reporting, we are organizing a webinar entitled "Physician Billing for 'Incident to' and Shared Care Services," which will comprehensively explain the differences between these services and guide physician billers toward correct billing procedures. Register, https://conferencepanel.com/conference/physician-billing-for-incident-to-and-shared-care-services

1. Solving the Mysteries Around
“Incident to”
&
Shared Care

2. 2
Objectives
• Define QHP providers
• Identify clinical staff and services they can
provide
• Understand which services require orders
• Explore the difference between “incident to”
and shared care services.
• Review specific guideline for each service
• Understand reimbursement issues
• Look at how other payers view these Medicare
policies

3. Basics
• All physician groups that employ QHPs
may be faced with billing Medicare for their
services.
• The key issue is differences in
reimbursement based on who reports a
service
– Medicare reduces QHP billed services by 15%
of the physician allowed amounts
– Huge compliance issue

4. QHP/NPP
• A QHP/NPP is a licensed health professional
• Recognized by Medicare as able to evaluate, treat
and be paid for medically necessary services on
the Part B physician fee schedule
– Qualified by education and training
• QHP must meet eligibility requirements to be
credentialed by Medicare and bill independently
• Examples: nurse practitioner, physician assistant,
clinical nurse specialist, certified nurse-midwife

5. Clinical Staff
• Person who works under the supervision of a
physician or other QHP professional
– Allowed by law, regulation and facility policy to
perform or assist in the performance of a specific
professional services
– 99211 or specific code based on TOS
– Service billed under physician QHP name
• Includes medical assistants, licensed practical
nurse, etc.

6. Incident to Requirements
• Performed in physician office
• Physician provides direct supervision
o Physician must be present in the office
suite and immediately available to furnish
assistance and direction throughout the
performance of the procedure.
o Supervising physician can be any physician in the
clinic
o Does not have to be physician the initiated care

7. Documentation
• Identity of performing provider
• Note indicating name of supervising/billing
physician was in the office suite at the time
of the service.
• Preferable to have physician order available
that ordered follow up by QHP or ancillary
service

8. Split/Shared Care
• Shared or split services are Evaluation and
Management (E/M) services performed
jointly between a physician and a non-
physician practitioner (NPP), in the same
group, in a facility setting.
• May not be performed in office setting (POS 11)
• Services may include both face-to-face and
non-face-to-face activities.

9. Commercial Payers
• Some may specifically exclude “incident
to”
• Cigna
• Some payers do not credential QHPs and
services should be billed under the
supervising physician

10. Commercial Payers…
– UHC allows “incident to” and shared care
billing.
• May require modifier –SA for incident to services
– HighMark follows “incident to” guidelines and
require
– If a particular payer credentials QHPs they may
follow incident to or shared care rules
– Check with your individual payers

11. THANK YOU
Register Now