August 05, 2015
Summer generally means vacations for everyone, and physicians are no exception. But what happens to patients when their physicians are on vacation? There are options for physician offices to continue to provide care to their patients, but the question that seems to come up annually is whether the physician assistant (PA) or nurse practitioner (NP) can provide services when the physician is out of the office and still bill as “incident to” services. The answer is no.
The Centers for Medicare and Medicaid Services (CMS) states that to qualify as “incident to,” services must be part of the patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. The physician does not have to be physically present in the treatment room when the service is being provided, but incident to rules state the physician must provide direct supervision in the office suite and be immediately available to render assistance and direction if needed (42 C.F.R §410.32 (b)(3)(ii)).
CMS further defines “office suite” as “limited to the dedicated area, or suite, designated by records of ownership, rent or other agreement with the owner, in which the supervising physician or practitioner maintains his/her practice or provides his/her services as part of a multi-specialty clinic.” So, while a vacationing physician may be available by phone to provide assistance, if he/she is not physically present in the office suite then the services would not qualify to be billed as “incident to” services.
Also, under "incident to" rules, if you are a solo practitioner, you must directly supervise the care. If you are in a group, any physician member of the group may be present in the office suite to supervise.
For inpatient or outpatient hospital services, and services provided to residents in a Part A covered stay in a skilled nursing facility, the unbundling provision (1862 (a)(14) provides that payment for all services are made to the hospital or skilled nursing facility by a Medicare intermediary (except for certain professional services personally performed by physicians and other allied health professionals). Therefore, "incident to" services are not separately billable to the carrier or payable under the physician fee schedule.
PAs, NPs and clinical nurse specialists who are enrolled in Medicare can provide and bill for services independently as the rendering provider when the supervisory physician is not present. The allowed amount is limited to 85 percent of the physician fee schedule, as opposed to 100 percent of the fee schedule when billing for "incident to" services.
It’s also important to be aware of the statutory and regulatory limits on the number of non-physician practitioners a physician can lawfully supervise. For more information, see CMA On-Call document #3000, "Allied Health Professional Relationships: Business Issues," which is available free to CMA members in our resource library.