Incident-to Requirements for Medicare

Question:

Thank you so much for all the information you gave out in Chicago at the KZA Convention. We always have great take-a-ways when we leave there. I do have a question for you regarding incident-to billing for Medicare.

One of my physicians is stating that her attorney told her being “under the same roof” of the building counts and you don’t necessarily need to be in the same suite. I am disagreeing stating they have to be in the same suite and even though she is available to run upstairs if needed, by her being on the second floor that goes against the “incident-to” rules. Am I correct?

Answer:

According to CMS In order to qualify as an incident-to service, there must be direct physician supervision of the NPP providing the service. Direct supervision means the physician must be present in the office suite and immediately available and able to provide assistance and direction throughout the time the service is performed. It does not mean that the supervising physician must be present in the room where the procedure is performed. Also the supervising physician must be immediately available (without delay). The supervising physician can be in another room As long as they are not performing a procedure that they cannot stop and go to help with the other patient then they are considered immediately available. CMS also clarifies that immediately available

CMS has clarified the office suite it is limited to the dedicated area or suite designated by records of ownership, rents, or other agreements with the owner.

Sources:https://med.noridianmedicare.com/web/jeb/topics/incident-to-servicesand CMS Medicare Benefit Policy Manual Pub. 100-2, Section 60https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

*This response is based on the best information available as of 06/16/22.