MEDICARE’S “INCIDENT TO” TABLE OF REQUIREMENTS
CRITERIA DO BILL DO NOT BILL
“Incident to” services provided in hospital
“Incident to” services are provided in
Location (inpatient or outpatient), skilled nursing
a physician’s office1
facility or nursing home
1. Physician2 must initially see the 1. No initial visit by the physician, or no
patient and set up a course of course of treatment established.
treatment BEFORE “incident to”
services are performed.
2. Physician’s participation (of a 2. No evidence of physician’s active
frequency that reflects active participation in ongoing care of the
participation) in ongoing care of the patient.
patient. See “Documentation”
Physician MUST BE physically 1. Physician is in a near-by building
present in the office suite where 2. Physician is only available by phone
services are provided and 3. Physician is not in the office suite
immediately available to staff during
the entire service
Services are: Services or supplies that are payable
An integral, although incidental under a separate benefit category, such
part of a physician’s professional as:
service; Diagnostic Tests (which have their
Commonly rendered without own supervision criteria)
charge or included in the Pneumococcal, influenza and Hep B
Types of Services physician’s bill; vaccines
Of a type that is commonly
furnished in a physician’s offices
or clinics; and
Furnished by the physician or by
auxiliary personnel under the
physician’s direct supervision
Auxiliary person is an employee, Auxiliary person is NOT an
leased employee or independent employee, leased employee or
contractor of the supervising independent contractor of either the
Providing the “Incident
physician OR the legal entity supervising physician OR of the legal
billing and receiving payment for entity billing and receiving payment
the “incident to” services/supplies. for the “incident to” services/supplies.
CRITERIA DO BILL DO NOT BILL
Documentation clearly No co-signature or legible identity
demonstrates a “link” between the and credentials of both the person
non-physician person’s services providing the service or the
to the supervising physician’s supervising physician.
services, which can be
established by: No indication of the supervising
Co-signature or legible identity physician’s involvement with the
and credentials of both the patient’s care and/or treatment plan.
Documentation by person who provided the
Supervising Physician service and the supervising
Indication of the supervising
physician’s involvement with
the patient’s care via notation
of his/her involvement within
the medical record OR
documentation from other
dates of service.
Documentation Requirements for CPT Code 99211 (by Trailblazer):
Trailblazer’s “Incident To” Services Manual:
10/1/10 Notice: http://www.trailblazerhealth.com/Tools/Notices.aspx?DomainID=1&ID=13937
CMS Internet Only Manual (IOM) 100-02, Chapter 15, Section 60:
Some “incident to” services to home bound patients may be allowed under a physician’s general
Non-Physician Practitioners - NNP (Advance Practice Nurse or Physician Assistant) can supervise
“incident to” services, so in all cases where the term “supervising physician” is used, the same
principles apply to NPPs supervising “incident to” services provided by ancillary staff.