“Incident to” and the Initial Visit – Evaluation & Management (E/M) Service Guidelines

Overview of Novitas Solutions Medical Review Department Findings

The Novitas Solutions Medical Review (MR) Department has observed a continued trend of the utilization of non-physician practitioners to perform initial office visits as "incident to" services. Documentation reviewed by the MR Department indicates that a non-physician practitioner performs the initial visit and the supervising physician documents a note in the medical record similar to the following:

This is incorrect use of the non-physician practitioner and incorrect billing under the "incident to" guidelines. This article from Novitas explains the Medicare definition of "incident to" services and the criteria that must be met to properly bill "incident to" services.

An initial history and physical performed by a non-physician practitioner, although the physician is documented as being present or in the office suite and immediately available, is not covered under the "incident to" guidelines. As outlined below, the physician MUST perform the initial service. This includes the history and physical, examination portion of the service, and the treatment plan. It is expected that the physician will perform the initial visit on each new patient to establish the physician-patient relationship.

Novitas Solutions MR Guidelines

Novitas Solutions MR (and I'm sure other Medicare Intermediaries) states that it will deny or down code claims for initial office visits billed as "incident to" when a non-physician practitioner performs the initial history and physical .

CMS defines "incident to" services as “services or supplies furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”

In order to be covered as "incident to" the physician’s service, the following criteria must be met:

• Services must be an integral, although incidental, part of the physician’s professional service;
• Commonly rendered without charge or included in the physician’s bill;
• Of a type that are commonly furnished in physician’s offices or clinics, and
• Furnished by the physician or by auxiliary personnel under the physician’s direct supervision

Direct Supervision Requirements

"Incident to" services must be performed under the direct supervision of the physician. CMS directs that “Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”

CMS further indicates, under direct supervision, “This does not mean, however, that to be considered "incident to", each occasion of service by auxiliary personnel (or the furnishing of a supply) need also always be the occasion of the actual rendition of a personal professional service by the physician. Such a service or supply could be considered to be "incident to" when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflects his/her active participation in and management of the course of treatment.” Hospital and skilled nursing facility services cannot be billed as "incident to" at any time.

For more information and direction on "incident to" services, refer to CMS’ Internet-Only Manual (IOM) Publication 100-02, Chapter 15, Section 60.