Incident-to guidelines are for Mid-Level Providers (physician assistants and nurse practitioners), also known as Non-Physician Practitioners (NPP), and are used to fill in the gaps in a practice by assisting physicians with the patient load. Services that have been properly provided and billed as “incident-to” will be reimbursed at 100% of the Medicare fee schedule amount for Medicare beneficiaries.

CMS has strict “incident-to” requirements. For example, the “incident-to” rule requires the physician to perform an initial service and/or subsequent services at a frequency which reflect active participation. The services must be performed in the office setting; the physician must be involved in the patient’s care; and the patient must be established with an established problem (plan of care) or complaint. The provider does not have to be physically present in the treatment room where the services are being rendered but must be in the immediate office/suite in order to render assistance if necessary. If the patient is new and/or a new problem arises, the attending physician would need to perform the service for that day as per the “incident-to” guidelines. If the NPP performs the service, the claim should be billed under the NPP’s provider number which reimburses at 85% of the physician fee schedule.

The incident-to requirements can be found in the Medicare Benefit Policy Manual, Chapter 15, Section 60-64C (PDF, 192 KB).

This commentary is a summary prepared by McKesson’s Business Performance Services division and highlights certain changes, not all changes, in 2014 CPT® codes relating to the specialty of academic, multi-specialty and office based physicians. This commentary does not supplant the American Medical Association’s current listing of CPT® codes, its documentation in the annual CPT Changes publications, and other related publications from American Medical Association, which are the authoritative source for information about CPT® codes. Please refer to your 2014 CPT® Code Book, annual CPT® Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes and interpretations that may not be reflected in this document.

CPT is a registered trademark of the American Medical Association (“AMA”). The AMA is the owner of all copyright, trademark and other rights to CPT® and its updates.

Author - Female

About the author

Lori Johnson, CPC, CPMA of Compliance—Academic, Multi-specialty and Office-based Medicine, McKesson Business Performance Services.