Incident-to and Shared Services: Demystifying Billing for Care Provided by Multiple Professionals

Abstract

This mini refresher course on billing for non-physician clinicians (NPCs) retraces the current rules about how to bill Medicare (and other payers) for medical services provided by them. In general, the reimbursement rate is determined by the NPI you enter into the claim: If it is the supervising physician’s NPI, the payment will be calculated at 100%, but if it is the NPC’s number, it will be paid at 85%.

The question is: When can you bill under the doctor’s provider number, and when do you have to use the NPC’s number? The general rule of thumb is that you can use the doctor’s number for “incident-to” or “shared visit” encounters. These terms refer to joint or follow-up care (never for new patients) in which the non-physician is caring for an established patient. Incident-to services are performed in a medical practice or doctor’s office “place of service,” while shared visits allow similar care and collaboration in a non-office facility. The author offers a table that summarizes the differences as follows:

• Incident-to

  • In doctor’s office

  • Performed by non-physician provider and/or staff

  • Billed under supervising physician’s NPI at 100% of the professional fee schedule or under the non-physician’s NPI at 85% of the professional fee schedule

  • Direct supervision (physician present in the location)

  • Established patients only

  • Supervising signature not required

• Shared visit

  • In facility (e.g., hospital)

  • Billed under provider providing substantive portion of service

  • Direct supervision not required during service

  • Patient can be new to the office

  • Physician must sign the substantive portion

The rules are complicated and nuanced. For example, telehealth visits performed by NPCs will always be paid at the 85% rate. Further complications include broad variations between states, and differences that exist within qualified Rural Health Clinics. The guidelines discussed in this article are for CMS programs (Medicare and Medicaid), but commercial payers vary greatly in how they reimburse NPC care.

Expert Commentary

Understandably, providers and billing staff often focus their attention on the different payment rates for non-physician providers: Will the billing and coding yield 100% of the scheduled fee; or will it only pay at the 85% rate? Good financial management leads us to maximize revenue whenever possible, but good practice management dictates that honest compliance to regulations must remain one of our highest priorities. When CMS introduced the 85% rate for incident-to services in 1997, there was a great deal of confusion. Fast-paced changes and constantly revised regulations have assured practices that confusion continues today.

Non-physician billing issues are a perennial area of concern that regularly pops up on the OIG’s annual work list — which means the auditors will be scrutinizing various aspects of non-physician bills.

The best advice for practice leaders: Do not neglect due diligence in staying on top of these regulations. Assign someone in the billing department or general management team to collect and disseminate new developments. Start new employees with solid training, and provide annual review of the rules. Noncompliance can get very expensive very quickly.

This article includes a useful table that can be accessed at: https://www.aafp.org/pubs/fpm/issues/2024/0500/shared-services-billing/jcr:content/root/aafp-article-primary-content-container/aafp_article_main_par/aafp_figure.enlarge.html

Source: Incident-to and Shared Services: Demystifying Billing for Care Provided by Multiple Professionals Betsy Nicoletti, MS, CPC, Family Practice Management, May/June 2024; https://www.aafp.org/pubs/fpm/issues/2024/0500/shared-services-billing.html