Incident-to Medical Billing Rule: Physician’s Direct Supervision is Must


Remember the Medicare program? There are three levels of supervision -- there's general, direct and personal. With general supervision, something is billed under the physician’s provider number. He doesn’t have to be there, he just has to be alive somewhere on the planet. He is responsible even though he’s not there. Go through this expert E & M coding article for more information.

For partial supervision, the other end of the spectrum. The physician has to be in the room with the patient when the service is provided. Direct supervision is in the middle. It means that the physician has be in the office suite and immediately available. Well, that sounds easy enough, doesn’t it? But one of the first things you have to look at is what's an office suite? And we would advise that you check with your local Medicare carrier if you’ve got anything questionable.

If you're in a free-standing building and you're the only suite in the building and that physician is either there or he’s not. It's pretty clear. But if you're in a professional building and let's say maybe you rent two floors on that professional building, can your physician be on the second floor while the nurse practitioner is on the first floor? Would your carrier allow that?

Our expert mentioned in an incident-to medical billing conference that you need to clarify that and make sure that that physician is in that office suite. Also, how are you going to prove he’s immediately available? Now, the Medicare regulation doesn’t tell us how we’re going to prove that. It's just says he has to be immediately available. In our experience what happens in the case of a CMS or a carrier audit is that the carrier will ask to see that provider, that supervising physician’s appointment schedule. That way, we prove that he is in the office.

What if he’s a teaching physician and he doesn’t have his own patient and maybe he’s not seeing his own patient. There still should be some sort of master schedule in the office that will help prove that that physician was there.

Now the supervision can be provided by another physician of the group practice but the service is billed under the supervising physician who is there. And in this case, Medicare guidelines are  clear that you bill it under the supervising physician who’s in the office and immediately available. And then in block 17 in your CMS-1500 form, you’ll enter that ordering physician’s name and NPI – the physician’s name and NPI as if he were a referring physician. So, it's billed under the supervising physician, the one who’s there, but you're referring physician the physician who sets the plan of care.

Now an employee of the physician. As we said, With-2, 1009 – it just has to represent an expanse to that physician, group practice or legal entity.

Remember that we can't bill physicians as incident-to. This is one of those things that CMS rules don’t come out say, “Thou shalt not do this.” However, we can't just be billing one physician as incident-to another to get around those credentialing delays that we’re all dealing with.

First of all, you're not going to meet incident-to criteria. When is one physician going to be just following a plan of care established by another physician? And check with your carrier on this as well. Some carriers have specifically said that you can't do this. Not all carriers have said that, but from a common sense perspective, is one physician ever really going to be incident-to another? So don't give them the habit of thinking you can bill one physician as incident to another.

You can have services that are incident-to in non-physician practitioner, meaning that you can have a nurse practitioner set up a plan of care and a medical assistant or nurse follows through on that. In that case, those serve as incident-to the nurse practitioner, not incident-to the physician as per medical billing rules.

So, you're not climbing the ladder to bill it under the physician if that plan of care was set up by that nurse practitioner. Services can be incident-to a nurse practitioner, PA or certified nurse specialist if they are the ones who set up the plan of care. So that’s incident-to.

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