Incident to is defined by the Centers for Medicare & Medicaid Services (CMS) as “an integral, although incidental, part of the physician’s personal professional services to the patient.” Incident-to services include those usually performed by clinical office staff (eg, vital signs, injections) or those performed personally by the physician (eg, minor surgery, fracture care, evaluation and management [E/M] of a patient).Services performed by nonphysician providers (NPPs) (eg, nurse practitioners, physician assistants [PAs], therapists, nurses, medical assistants, technicians) that do not have their own provider number are reported as incident to under the physician’s provider identification number (PIN) and are paid according to the physician fee schedule. In other words, they are reported as if they were performed by the physician.Licensed NPPs (eg, clinical nurse specialists, clinical nurse practitioners) may provide medically necessary services within their state’s scope of practice without direct physician supervision and may report their services separately using their own PIN. They may perform services that are ordinarily performed by clinical office staff (eg, nurses, medical assistants) or by the physician. Payment for NPPs billing under their individual PINs is typically a percentage of the physician fee schedule. A licensed NPP who does not have a PIN must follow the carrier’s incident-to provisions. Medicare requires the services of PAs to be incidental to a physician; thus, PA services are only reported under the physician’s PIN.State Medicaid and commercial payers may follow the Medicare requirements or have their own specific rules addressing incident-to provisions. These provisions are not applicable to residents because they must follow the Physicians at Teaching Hospitals (PATH) guidelines.The following outlines Medicare requirements for incident-to services. Again, these are applicable to any employee, leased employee, or contracted employee who does not report services under an individual PIN.Remember that these guidelines do not apply to NPPs who have their own PIN and provide services under their state’s scope of practice.Services can be reported as incident to when the NPP (with his or her PIN) and the physician see the patient on the same day of service. The physician is required to perform some part of the key components of the E/M service and the NPP and the physician must document their portions of the service. The service should be reported based on the performance and documentation of the combined services as if the physician performed the entire service. However, only the physician’s face-to-face time is used to determine the level of E/M service.Detailed requirements for reporting split or shared E/M services (physician and NPP provide face-to-face services during the same patient encounter) are outlined in the CMS Transmittal 1776 dated October 25, 2002. The following outlines CMS requirements for reporting split or shared E/M services:Diagnostic tests do not fall under the incident-to provisions. However, the CMS requires certain levels of physician supervision for covered diagnostic tests. The Medicare Physician Fee Schedule database includes an indicator on each Current Procedural Terminology and Healthcare Common Procedure Coding System code that defines the level of supervision required. The 3 levels of physician supervision areAn NPP, a patient, or a family member can document a chief complaint, review of systems, and past, family, and social history. The physician must document the history of present illness (HPI). If the HPI is documented by an NPP, the medical record must reflect the physician’s actual review of the HPI and interaction by indicating agreement or disagreement or noting supplemental information.The supervising physician must document his or her supervision of the encounter and cosign the encounter note. Documentation may be as simple as service performed/provided under the direct supervision of Dr X. The supervising physician’s signature must be legible.When a split or shared service is performed, the physician and NPP must document their portions of the service. If the E/M service is reported based on counseling or coordination of care, the physician must document the total time spent in counseling or coordination of care and a summary of the issues discussed or coordination provided.Keep in mind that these are Medicare billing requirements. You can access a copy of the CMS incident-to requirements and Transmittal 1776 at www.cms.hhs.gov. State Medicaid programs and commercial payers may follow the Medicare rules or have their own policies addressing incident-to provisions and certified NPP billing. Check with your payers and obtain a copy of their specific policies. Then adhere to the rules!