Billing and Coding: Incident To Clarification for OPPS and CAH Outpatient

In response to provider requests, Noridian Healthcare Solutions, LLC (Noridian) provides the following key points related to the “incident to” regulations in the outpatient hospital setting. Note: There is no "incident to" in the inpatient setting. Medicare may reimburse the costs of services provided either: 1. delivered personally by eligible practitioners, e.g., MD, NP, PA; or 2. delivered by hospital personnel working “incident to” the eligible practitioner’s care. When hospital personnel provide services, the following payment requirements must be met. Services delivered incident to the services of an eligible practitioner must: o Be an integral although incidental part of a physician’s/non-physician practitioner’s (NPP’s) professional service(s) and, hence, must always occur after an initial patient care service is provided by an eligible practitioner; o Be delivered in accordance with a valid and signed order , i.e., written by “a practitioner who is authorized to write orders by hospital policy and in accordance with state law…” 42 CFR§482.12(c); o Be delivered under the supervision of a physician who is an employee or has another contractual relationship with the hospital and is immediately available to provide assistance to the personnel delivering the service; •"Immediately available" in the outpatient hospital setting means that the physician must be available in the same time-frame as the personnel designated to manage cardiac arrests (codes) in the hospital. •The supervisor need not be in the same department as the ordering physician/NPP or in the same department in which the services are rendered but must be on the physical premises where and when the patient receives services. The physician/NPP that provides the oversight may not bill for the services of hospital employees. Only the hospital may bill for the services of hospital employees. All service providers must work in accordance with their skills, licensure, and/or other hospital and other Medicare requirements.