Medicare contractor clarifies "incident-to" rules for allergy therapy

Medicare’s “incident-to” rules become less mysterious the more you learn about them. But that doesn’t mean physicians and practice administrators aren’t still sometimes baffled by how they work.

Earlier this year at a forum, Wisconsin Physician Services (WPS), a Medicare administrative contractor, answered a question about providing allergy therapy that surprised many. In essence, the question was: If a nurse in the practice administers allergy injections to a patient, can the practice bill the service under the physician's Medicare provider number, even though the physician is not treating the allergy?

In its response, WPS referenced Medicare Learning Network Matters article Special Edition (SE) 0441, which addresses incident-to rules. WPS noted that one of the requirements of incident-to billing is that the billing physician is the one treating the patient for that condition or situation. So, if the physician in question is treating the patient for the allergy (not just providing the injections), then this situation could meet the incident-to requirements.

If the physician is not treating the patient for the allergy, then, according to WPS, this situation does not meet the incident-to requirements, and the physician cannot bill for the administration of the injection. WPS advises notifying the patient of non-coverage in this scenario.

Even if this particular situation wasn’t on your radar, it should show that incident-to rules are definitely being scrutinized by Medicare administrative contractors.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians

Posted on Mar 07, 2016 by David Twiddy