Incident-To Billing
Incident-to billing allows services provided by non-physician practitioners (NPs, PAs, clinical social workers) to be billed under the supervising physician's NPI at 100% of the physician fee schedule, rather than the NPP's lower reimbursement rate of 85%.
What is Incident-To Billing?
Under Medicare's incident-to policy, services provided by non-physician practitioners (NPPs) in an outpatient office setting can be billed under the supervising physician's National Provider Identifier (NPI) at 100% of the Medicare Physician Fee Schedule — versus billing under the NPP's own NPI at 85% of the fee schedule. Four requirements must all be met: (1) the patient must be an established patient with an established plan of care previously initiated by the physician; (2) the service must be a follow-up to a condition the physician has already evaluated and for which a treatment plan exists; (3) the physician must be present in the office suite (in the same suite, not merely in the building) when the NPP provides the service; and (4) the NPP must be carrying out the physician's established plan of care — not addressing a new problem or new diagnosis. Incident-to billing cannot be used for new patient visits or when a new problem requires a new plan of care. The financial impact is significant: a 15% revenue difference on an NP seeing 20 patients per day at $75 average allowable equals $225 per day, or approximately $56,250 per year per full-time NPP. The OIG frequently cites incident-to as a billing compliance risk area, with improper billing occurring when the physician was not present on-site.
Why It Matters for Healthcare Analytics
Practices must track which NPP visits are being billed incident-to vs. under the NPP's own NPI, and whether the supervisory requirements are consistently met. Audit exposure from improper incident-to billing can result in significant repayments. Simultaneously, failing to use incident-to billing when all requirements are met leaves meaningful revenue on the table.
How Vizier Tracks Incident-To Billing
Upload your billing data and ask "What percentage of our NP and PA visits are billed incident-to vs. under their own NPI, and what is the revenue impact?" — Vizier calculates the revenue difference by provider and identifies scheduling patterns that suggest supervisory requirement gaps.