Billing for Non-physician Clinician Services

There are three billing options for services provided by non-physician clinicians:

NPCs may enroll and bill under their own national provider identifier (NPI) or reassign their billing rights to allow their employer or contractor to use their NPI.
- Medicare pays 85% of the fee schedule for services billed under the NPC’s NPI (note: Medicare uses the title non-physician provider)
If a service meets certain requirements, the NPC may report services “incident-to” a physician’s service. Services billed as “incident-to” are filed using the physician’s NPI and are paid 100% of the Medicare fee schedule.
Services provided in institutional settings may be billed as a “shared/split” visit. The visit is billed under the NPI of physician or NPC who provided the substantive portion of the service.

Incident-to billing

What are the Medicare requirements for incident-to billing?

To be billed incident-to, a service 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 the physician’s offices or clinics, and

✔️ furnished by the physician or auxiliary personnel under the physician’s direct supervision.

Additionally:

✔️ The physician must perform initial service and devise a plan of care. The NPC follows the plan of care as developed by the physician. The physician must continue to play an active role in the patient’s care and provide services at a frequency that demonstrates their involvement.

❌ Incident-to services cannot be provided to new patients or for new problems for existing patients (unless documentation supports a face-to-face occurred with the physician during the encounter and they initiate a course of treatment).

✔️ Both the supervising physician and NPC must be enrolled in Medicare (or with payer).

✔️ The physician must have a relationship with the legal entity that is billing and receiving payment for the services.

✔️ The physician must have an employee type relationship to the NPC, such as 1099, W-2 or contract employee to contribute to the practice expense billing under the physician.

❌ Services that can be provided without physician supervision may not be billed incident to unless there was direct supervision.

❌ Incident-to does not apply to institutional settings (e.g., hospital, skilled nursing facility, etc.).

What are the direct supervision requirements?

Under direct supervision, a physician must be on site, in the office suite, and immediately available should issues arise.
For group practices, supervising physician does not need to be the same physician who developed the patient’s initial plan of care (i.e., physicians may provide cross coverage for each other). Services should be reported using the NPI of the physician who provided direct supervision on the date of service.

What are the incident-to documentation requirements?

Documentation should include:

the physician onsite who provided direct supervision,
the name and professional designation of individual rendering service,
Documentation from other dates of service (e.g., initial visit establishing connection two clinicians), and
Documentation demonstrating physician’s continued involvement in treatment.

Split or shared billing

What is a “split/shared” visit?

In a split/shared visit, both the physician and NPC perform a portion of an E/M service for the same patient on the same date of service. Unlike incident-to services, split/shared visits can be provided to new and established patients, and for initial and subsequent encounters.

Medicare only pays for split/shared visits in institutional settings, including places of service:
- Hospital inpatient (21)
- Hospital outpatient (19 and 22)
- Emergency department (23)
- Nursing facility (31 and 32)
The physician and NPC must be part of the same group.
The service is reported under the NPI of the clinician who performed the “substantive portion” of the visit.

The substantive portion of the visit may be based on time or medical decision making, whichever is used to select the level of service.
- When using time, substantive portion is determined by who spent more than half the total time performing the visit.
  - Total time includes both face-to-face and non-face-to-face time.
  - Only distinct time may be counted.

When using medical decision making, 2024 CPT® Professional Edition states:

“…performance of a substantive part of the MDM requires that the physician(s) or other [qualified health care professionals] QHP made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management. By doing so, a physician or other qualified health care professional has performed two of the three elements used in the selection of the code level based on MDM. If the amount and/or complexity of data to be reviewed and analyzed is used by the physician or other qualified health care professional to determine the reported code level, assessing an independent historian’s narrative and the ordering or review of tests or documents do not have to be personally performed by the physician or other qualified health care professional, because the relevant items would be considered in formulating the management plan. Independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the physician or other qualified health care professional if these are used to determine the reported code level by the physician or other qualified health care professional.”

Documentation should identify the physician and NPC who performed the visit. The individual who reports the service must sign and date the medical record.

Note: Payers may have different policies for incident-to and split/shared visits. Check with your local provider relations representatives to verify their requirements.