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Policy No:  136

Originally Created: 01/01/2019

Section: Administrative

Last Reviewed:

Last Revised:

Approved: 04/04/2019

Effective: 01/01/2019

This policy applies only to physicians, facilities and other qualified health care professionals.

Definitions

Incident To

"Incident To" - those services that are furnished by an Non-Physician Practitioner (NPP) provider incident to physician or other eligible practitioner's (e.g. nurse practitioner, see list of included practitioners in "NPP" section below) professional services in the physician's or other eligible practitioner's office (whether located in a separate office suite or within an institution) or in a patient's home.

Immediately Available

"Immediately Available" - meaning "without delay." The supervising physician/or other eligible practitioner is in the office suite or patient's home, readily available and without delay, to assist and take over the care as necessary.

Non-Physician Practitioner (NPP)

A provider that practices either in collaboration with or under the supervision of a physician or other eligible practitioner such as an advanced practice professional nurse (e.g. nurse practitioner). Examples of NPP include physician assistant, nurse practitioner, clinical nurse specialist, registered nurse, nursing assistant, nurse's aide, nurse midwife, therapy aide, clinical psychologist, home health aide, and chaplain.

Palliative Care

Specialized medical care for people with serious illness. Providing patients with relief from the symptoms, pain, and stress of a serious illness, regardless of diagnosis.

Policy Statement

Generally, our health plan requires that all licensed and credentialed providers bill for all services they perform under their own name.  A licensed provider may not submit claims for services of and on behalf of (i.e. ‘incident to') another provider (e.g. NPP).

However, ‘incident to' services are acceptable to be billed in a palliative care setting.  The NPP provides an integral aspect of palliative care as a commonly rendered service. 

Palliative care services are specialized medical care for people with serious illness.  Care is focused on providing patients with relief from symptoms, pain and stress of a serious illness regardless of the diagnosis(es). 

Qualifications for providing ‘incident to' services include, but are not limited to:

  • Services are part of the member's normal course of treatment.
  • The physician or other eligible health care practitioner (e.g. nurse practitioner) personally performs the initial service and remains actively involved in the course of treatment and must provide direct supervision and/or be "immediately available."
  • The member's medical record should document the requirements for ‘incident to' services.
  • The ‘incident to' service is rendered without charge (service is submitted on the physician or other eligible health care practitioner's claim).

Non-Physician Practitioner (NPP) Billing Guidelines

  • NPP's without a national provider identifier (NPI) will bill under the physician's or other eligible health care practitioner's NPI number.
  • Must perform health services under direct supervision.
  • Must be an employee or independent contractor of a physician group if service is performed in a satellite office.
  • Service settings include in an office, patient's home, office within a skilled nursing facility (SNF) patient setting.
  • NPPs cannot initiate course of treatment and care plan for each new problem.
  • NPPs cannot provide all the subsequent treatment.
  • ‘Incident To' Billing Not Allowed:
    • Under Medicare Hospice benefit.
    • In inpatient setting for Medicare patients.
    • Visits occurring outside an office, home or SNF office OR for a hospice patient.
    • Services occurring in a satellite office where no physician is present.
    • For non-palliative care services.

NPP types may provide ‘incident to' services for palliative care that are within the scope of their licensure and training and authorized under State law.  Furthermore, a NPP cannot supervise another NPP. 

Current Procedural Terminology (CPT®)/Healthcare Common Procedure Coding System (HCPCS) Codes Acceptable for ‘Incident To' Billing

Acceptable CPT/HCPCS Codes

  • 99497 – Advance Care Planning, face-to-face with patient, family member(s) and/or surrogate.
  • 99498 – Advance Care Planning, face-to-face with patient, family member(s) and/or surrogate.
  • 99366 and 99367 – Medical team conference, direct face-to-face contact with/without patient or family.
  • 99374, 99375, 99379, and 99380 – Care plan oversight services.
  • 90832 and 90834 – Clinical Social Worker Visits.  Individual psychotherapy insight-oriented.
  • 99341-99345 and 99347-99350 – Home Visits (Physician/Nurse Practitioner).
  • 99509 – Home visit for assistance with activities of daily living and personal care.
  • 99510 – Home visit for counseling for individual, family, or marriage.
  • 1150F – Home Visit (Physician/Nurse Practitioner.  Documentation stating a patient has a substantial risk of death within one year.

References

Centers for Medicare & Medicaid Services (CMS), 2016.  ‘Incident To' Services. MLN Matters Number: SE0441.

Centers for Medicare & Medicaid Services (CMS), 2017. Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services. Section 60.4 – Services Incident to a Physician's Service to Homebound Patients Under General Physician Supervision.

Noridian Healthcare Solutions, 2017. ‘Incident To' Services

Palmetto GBA, 2017. ‘Incident To' and Split/Shared Services Frequently Asked Questions

Claims and Payment; Claims Submission

Cross References

None

Disclaimer

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