Last Modified: 11/7/2024
Location: FL, PR, USVI
Business: Part B
1Q: Can 99211 be billed incident-to?
1A: 99211 is an established patient office or other outpatient visit that may not require the presence of a physician. To bill incident-to, the incident-to rules must be met. To ensure the services meet those requirements, utilize the
incident-to tool on our website. This applies to E/M services prior to 2021 and after.
2Q: Can hospital visits provided by a nurse practitioner be billed as incident-to his/her supervising doctor, as long as the doctor is also in the facility seeing patients?
2A: The incident-to provisions do not apply to hospital settings.
The only exception to this is when the physician establishes an office within a nursing home or other institution. Where a physician establishes an office within a nursing home or other institution, coverage of services and supplies furnished in the office must be determined in accordance with the incident-to a physician’s professional service provision as in any physician’s office. A physician’s office within an institution must be confined to a separately identified part of the facility which is used solely as the physician’s office and cannot be construed to extend throughout the entire institution. Thus, services performed outside the office area would be subject to the coverage rules applicable to services furnished outside the office setting.
3Q: If a new patient comes into the office and sees our physician assistant (PA), can our PA bill this as incident-to the physician, who is also in the office seeing patients?
3A: No. In order for the service to qualify as incident-to, an initial encounter must have occurred between the physician and the patient, and a course of treatment established by the physician. In this situation, services performed by the PA do not meet the incident-to requirement and would not qualify because this is a new patient. The claim would be billed listing the PA as the performing provider.
4Q: Can services of a physical therapy assistant be billed incident-to a physician’s services?
4A: No. The services provided by physical therapist assistants (PTAs) cannot be billed incident-to a physician/non-physician practitioner’s (NPP), because PTAs do not meet the qualifications of a therapist. Only the services of a licensed/registered physical therapist can be billed incident-to a physician service. PTAs may not provide evaluation services, make clinical judgments or decisions, or take responsibility for the service. PTAs act at the direction and under the supervision of the treating physical therapist and in accordance with state laws. The services of the PTA are only billable when provided under the direct supervision of the physical therapist and under their NPI number.
5Q. When billing Medicare for injections that are provided incident-to by a nurse practitioner (NP) or other non-physician practitioner (NPP), does the supervising physician have to sign off on the injection?
5A. No. Although the injections are billed under the supervising physician’s NPI, he or she is not required to see the patient or document any notes in the patient’s medical record.
A service that is billed as incident-to is one that is furnished as an incidental but integral part of the physician’s professional services in the course of the diagnosis or treatment of the patient’s injury or illness.
Therefore, in order to bill for injections provided incident-to by an NP or NPP, the following criteria must be met:
• Supervising physician must be in the office at the time the injection is given by the NP or NPP
• Supervising physician must have established a treatment plan for the condition for which the injection is provided
• Documentation contained within the patient’s medical record should demonstrate the link between the non-physician’s service and the precedent physician’s service to which it is incidental
Note: If the NP is billing under his or her own NPI, the supervising physician is not required to be in the office -- unless the physician’s presence is required by state law.
6Q: Regarding incident to, during the COVID-19 Public Health Emergency (PHE) the requirements were changed to include being available via audio and/or visual technology, and this was extended to the end of 2024. Is this still valid information?
6A: As explained by CMS in the calendar year (CY) 2024 final rule:
Under Medicare Part B, certain types of services, including incident to physicians’ or practitioners’ professional services, are required to be furnished under specific minimum levels of supervision by a physician or practitioner. For most services furnished by auxiliary personnel incident to the services of the billing physician or practitioner, direct supervision is required.
Outside the circumstances of the PHE, direct supervision requires the immediate availability of the supervising physician or other practitioner, but the professional need not be present in the same room during the service.
We have established this “immediate availability” requirement to mean in-person, physical, not virtual, availability. Through the March 31, 2020, COVID-19 interim final rule with comment period (IFC), we changed the definition of “direct supervision” during the PHE for COVID-19 as it pertains to supervision of diagnostic tests, physicians' services, and some hospital outpatient services, to allow the supervising professional to be immediately available through virtual presence using two-way, real-time audio/video technology, instead of requiring their physical presence.
We will continue to define direct supervision to permit the immediate availability of the supervising practitioner through real-time audio and visual interactive telecommunications through December 31, 2024. We will consider addressing this topic in possible future rulemaking.
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