Billing / Coding FAQs

When evaluation and management services are furnished incident-to a physician's service by a nonphysician practitioner, the physician may bill the CPT code that describes the evaluation and management service furnished. CPT code 99211 is an established patient office or other outpatient visit that may not require the presence of a physician or other qualified health care professional. 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.  

Reference 

• CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, section 30.6 

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. 

Reference

• Medicare Benefit Policy Manual, Chapter 15, Section 60
• Medicare National Coverage Determinations Manual, Chapter 1, Part 1 (Sections 10 - 80.12), Section 70.3

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.

Reference

• CMS internet-only manual (IOM) Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15 Covered Medical and other
   

No. The services provided by physical therapist assistants (PTAs) cannot be billed incident-to a physician/non-physician practitioner (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's 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.

Reference

• CMS (IOM) Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 230 

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.

Reference

• CMS IOM Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15 Covered Medical and other Health Services, Section 60 Services and Supplies Furnished Incident to a Physician’s/NPP’s Professional Service
   

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 service(s) must be:

• An integral, although incidental, part of the physician’s professional service
• Commonly rendered without charge or included in the physician’s bill
• Of a type that are commonly furnished in physician’s offices or clinics
• Furnished by the physician or by auxiliary personnel under the physician’s direct supervision

Reference 

• CMS IOM Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 60.1