DID YOU KNOW? Medicare "incident to" billing

2018-02-13 | , February 5, 2018

Currently, the Medicare program covers services that PAs provide in all practice settings at a uniform rate of 85 percent of the physician fee. Generally, all services for which Medicare would pay if provided by a physician are also covered when performed by a PA, in accordance with state law. Those include services provided in the office or clinic, any department of the hospital – including the emergency department – a skilled nursing facility, an ambulatory surgical center, and the patient’s home. Medicare defers to state law on the requirements for collaboration. PA claims are submitted to Medicare at the full physician charge. By use of the PA’s National Identifier (NPI) number, the Medicare Contractor is alerted to pay at the 85% level.

Medicare rules do not require the physician to see or treat a patient or to be physically on site when a PA treats a patient if the service is billed to Medicare under the PA’s name. PAs are authorized to treat new patients or established patients with new medical problems when billing under their name and NPI.

One of the more confusing provisions with Medicare reimbursement is as it pertains to “incident to” billing.   The “incident to” provision allows PA-provided services to be billed under a physician name. Payment is made at 100 percent of the fee schedule. This may occur only if:

1. The physician personally treats, establishes the diagnosis, and develops the plan of care for a Medicare patient on the first visit for a particular medical problem.

2. A physician in the group (need not be the same physician who originally treated the patient) is physically on site when the PA provides follow-up care on a future visit.

3. The physician personally treats and diagnoses established Medicare patients who present with new medical problems.

4. The physician has an active part in the ongoing care of the patient. Subsequent services by the physician must be of a frequency that reflects his/her continuing active participation in, and management of, the course of the treatment.

If a patient is seen for follow up and has a new problem, the visit may not be billed under the “incident to” provision. This encounter must be billed under the PA’s NPI and reimbursement is at 85% of the fee level. 

The information contained in this post is provided for informational purposes only and should not be construed as legal or professional advice on any subject matter. This website should not be used as a substitute for legal advice from a licensed attorney, or other professional advice.

This information was adapted with permission from AAPA website.