SERVICES PROVIDED AS

SERVICES PROVIDED AS “INCIDENT TO A PHYSICIAN’S
PROFESSIONAL SERVICE” IN THE OFFICE/CLINIC SETTING

Services commonly furnished in the physician’s office or physician directed clinic are considered “incidental to the physician’s personal professional service” when these services are provided as an integral part of the personal professional service of the physician in the course of diagnosis or treatment of an injury or illness. These services may be reimbursed under the physician’s fee schedule, however, the following criteria must be met:

The service must be furnished to diagnose or treat an illness.

The service in question must be commonly furnished in the physician’s office.

The services are provided by the auxiliary personnel (nurses, technicians, therapists, including physical therapists and medical assistants) that are employed by the physician. The auxiliary personnel must work under the direct supervision of the physician when rendering services to patients. Direct supervision means that the physician must be present in the office suite and immediately available to provide assistance and direction during the time the auxiliary person is performing the service. The physician does not have to be present in the same room with the auxiliary personnel or see the patient during an “incident to” visit. Auxiliary personnel can only perform the services ordered by the physician. Additionally, auxiliary personnel must document in the patient’s medical record all services rendered to the patient, provide a statement that verifies they are working under the supervision of the physician and have the physician countersign their note.

In addition to the above categories of auxiliary personnel, a physician may also have the services of non-physician practitioners covered as “incident to” the physician’s professional services. Non-physician practitioners are professionals licensed by a State, under various health programs, to assist or act in place of the physician. These professionals include: Certified Nurse Midwives, Certified Registered Nurse Anesthetists, Clinical Social Workers, Physician Assistants, Nurse Practitioners (APRN’s), Clinical Nurse Specialists. Services provided by these non-physician professionals include:

services ordinarily rendered by a physician’s auxiliary personnel such as taking blood pressures, giving injections or changing dressings.

services ordinarily performed by the physician such as minor surgery, setting casts for simple fractures, reading x-rays, and other activities that involve evaluation or treatment of a patient’s condition

For Evaluation and Management services to qualify as “incident to” a physician’s service, the following conditions are required:

the MD must have evaluated a patient’s medical problem to initiate a course of treatment. This means that “incident to” must never occur with the new patient.

the non-physician practitioner may render established E&M office visit codes. The physician must be present in the office suite and immediately available to provide assistance and direction during the time the non-physician practitioner is performing the service.

there must be subsequent services by the physician of a frequency that reflects continued, active participation in the management of the course of treatment.

if the non-physician practitioner is following up on the care of an established patient for a condition that was initially evaluated by the physician and is now faced with a new medical problem, the physician must participate in the evaluation of the new problem. This participation must be evidenced by the physician’s documentation in the patient’s medical record.

non-physician practitioner personnel must document in the patient’s medical record all services rendered to the patient, provide a statement that verifies they are working under the supervision of the physician and have the physician countersign their note.

The “incident rules” do not apply to auxiliary or non-physician practitioners who are employed by the hospital. The above rules only apply to services rendered in the offices of physicians in private practice or those rendered in multi-physician clinics where the auxiliary personnel or non-physician practitioners are employed by the physician or clinic.

Effective January 1998, non-physician practitioners, (APRNs, CNs, PAs, NPs) will no longer be restricted by the setting in which the services are provided to the patient. The non-physician practitioners must be employed by the physician or physician practice, enrolled and credentialed in Medicare and other health insurance programs and use their own designated provider number. Payment will equal 80% of the lesser of either the actual charge or 85% of the physician’s fee schedule. Non-physician practitioners may continue to bill incident to the physician; those choosing to do so must continue to follow the regulations as outlined above and will be paid at 100% of the physician’s fee schedule.