1) Is this a new patient, OR a new problem for an established patient?
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'Incident to' rules do not apply.
‘Incident to’ a physician’s professional services means that the services or supplies are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.
Coverage of services and supplies incident to the professional services of a physician in private practice is limited to situations in which there is direct physician supervision of auxiliary personnel.
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2) Does the person performing the service meet the definition of auxiliary personnel?
Auxiliary personnel means any individual who is acting under the supervision of a physician, regardless of whether the individual is an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician. Likewise, the supervising physician may be an employee, leased employee or independent contractor of the legal entity billing and receiving payment for the services or supplies. Individuals who have been excluded from the Medicare program or have had their Medicare enrollment revoked cannot act as auxiliary personnel.
However, the physician personally furnishing the services or supplies or supervising the auxiliary personnel furnishing the services or supplies must have a relationship with the legal entity billing and receiving payment for the services or supplies that satisfies the requirements for valid reassignment. As with the physician’s personal professional services, the patient’s financial liability for the incident to services or supplies is to the physician or other legal entity billing and receiving payment for the services or supplies. Therefore, the incident to services or supplies must represent an expense incurred by the physician or legal entity billing for the services or supplies.
Thus, where a physician supervises auxiliary personnel to assist him/her in rendering services to patients and includes the charges for their services in his/her own bills, the services of such personnel are considered incident to the physician’s service if there is a physician’s service rendered to which the services of such personnel are an incidental part and there is direct supervision by the physician.
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‘Incident to’ rules do not apply. Service can only be billed under the performing provider’s NPI (national provider identifier) if that provider is enrolled as a Medicare provider.
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3) Is the service being provided in place of service 22 (outpatient hospital), 19 (off campus outpatient hospital) or 23 (emergency department)?
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'Incident to’ rules do not apply in these locations.
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4) Is the patient being seen in a NF (nursing facility) or SNF (skilled nursing facility)?
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4a) Were the services performed in a section of the facility that meets the definition of an office?
The office cannot be construed to extend throughout the entire facility.
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‘Incident to’ rules do not apply.
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5) Is there a physician who is a member of the group or practice providing direct supervision at the time of service?
For incident to, direct supervision is defined as: the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary.
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‘Incident to’ rules do not apply. Service can only be billed under the performing provider’s NPI (national provider identifier) if that provider is enrolled as a Medicare provider.
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6) Was the patient initially seen by a physician who is a member of the group or practice and was a plan of care developed?
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‘Incident to’ rules do not apply
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7) Does the patient’s medical records support continued involvement by the physician who initiated the plan of care?
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'Incident to' rules do not apply, however the service can still be direct billed using the NPP (non-physician practitioner) as the rendering provider. The NPP must have an NPI (national provider identifier) number and be enrolled as a Medicare provider.
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8) Does the documentation for service(s) billed include the date and legible signature of the rendering provider?
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For medical review purposes, Medicare requires that all services provided/ordered, whether incident to or not, be authenticated by the author of the medical record. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable. Please review CMS signature guidelines for medical review purposes, Publication 100-8, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, Section 3.3.2.4 - Signature Requirements
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‘Incident to’ rules apply
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