If your practice bills Medicare for services provided by non-physician practitioners (NPPs) — like nurse practitioners, physician assistants, or clinical nurse specialists — then you’ve probably heard of “incident-to” billing.
But let’s be honest, the rules around it aren’t exactly easy reading. One missing signature or documentation error, and you’re looking at denied claims, audits, or worse — repayment demands from CMS.
So what exactly is “incident-to” billing? And how can your practice do it right — without risking compliance headaches?
In this guide, we’ll walk you through everything you need to know about incident-to billing and how to stay compliant with Medicare’s updated rules.
What Is “Incident To” Billing?
“Incident to” billing is a Medicare rule that allows certain services performed by non-physician practitioners (NPPs) to be billed under the supervising physician’s National Provider Identifier (NPI) number. This allows the service to be reimbursed at 100% of the Medicare Physician Fee Schedule (PFS) instead of the 85% typically paid for services rendered directly by NPPs.
In practical terms, if a nurse practitioner (NP), physician assistant (PA), or other qualified healthcare provider delivers follow-up care based on a physician-created treatment plan, and the physician is present in the office, the practice may bill that encounter as if the physician provided the care.
This rule was designed to help practices work more efficiently and utilize their clinical staff more effectively while still ensuring physician oversight. It can significantly increase revenue but comes with strict requirements.
Why Should Practices Care About “Incident To”?
Revenue Impact: When you bill under a physician’s NPI using incident-to rules, you receive 100% reimbursement from Medicare. Otherwise, billing under an NP or PA only gets you 85%. That 15% difference adds up, especially for high-volume practices.
Workflow Flexibility: Physicians can delegate routine follow-up tasks, chronic care management, or medication adjustments to NPPs while focusing on complex cases.
Patient Access: Leveraging NPPs more efficiently can improve scheduling and reduce wait times for patients.
Example:
- A family medicine practice sees 100 Medicare patients each week for established problems.
- If half of those visits are performed by NPPs and billed as incident to, the practice could collect 15% more per visit.
- If each visit is $100, that’s $750 more per week or $39,000 per year.
Incident To Billing Guidelines (Updated for Medicare)
Medicare’s guidelines for incident to billing haven’t changed dramatically in 2025, but enforcement and documentation expectations have tightened. Practices need to follow these rules carefully to stay compliant:
1. Who Can Bill “Incident To”?
Only a physician (MD or DO) can bill incident to. The services must be:
- Provided by an NPP (NP, PA, CNS, or other licensed personnel)
- Furnished under the direct Supervision of the billing physician
Direct Supervision in 2025 still means:
- The physician must be physically present in the office suite
- The physician must be immediately available to help if needed
- Telehealth or phone supervision does not qualify
2. Which Services Qualify?
- The service must be integral to the physician’s plan of care
- It must be routine follow-up or maintenance care
- The service must occur in a non-institutional setting, like a physician’s office (POS 11)
You cannot bill incident to for:
- New patient visits
- New problems or conditions not previously addressed by the physician
- Services in hospitals, SNFs, or outpatient hospital departments
3. Documentation Requirements
To protect against audits, every incident to claim should include:
- The initial visit note by the physician establishes the diagnosis and plan
- Clear reference in the NPP’s note that care was provided under that plan
- A record of the supervising physician’s presence during the service
- An NPP signature, not just the physician’s
Some practices even keep a log or sign-in sheet to prove physicians were physically present during office hours.
Medicare’s “Incident To” Billing Checklist (2025)
Here’s a quick Medicare incident billing checklist your billing staff and providers can use:
Use this before billing under a physician’s NPI for services delivered by an NPP (like a nurse practitioner or PA) .
1. Confirm if “Incident-to” Billing Even Applies
- Setting check: You must be in a non-institutional setting like a private practice or outpatient clinic—not a hospital or SNF.
- Medicare rules?: Make sure Medicare or your specific payer allows “incident-to” billing. Not all do.
- Physician is in-house: The supervising physician needs to be physically present in the office suite and immediately available. Remote Supervision doesn’t count.
2. Patient Relationship Must Be Physician-Led
- First visit by physician: The initial evaluation and care plan must come from the physician—not the NPP.
- Plan of care on file: The NPP must follow the physician’s established care plan.
- Any changes = new eval: If the NPP adjusts the plan (e.g., new meds, diagnosis change), the physician must re-evaluate before “incident-to” applies again.
3. Supervision Means Hands-On, Not Hands-Off
- Physician must be in the building: “Direct supervision” doesn’t mean in the same ZIP code—it means in the office suite.
- No phone supervision: The physician cannot supervise remotely or be on call. They must be available for immediate help, in person.
4. Documentation Must Be Tight
- NPP must note they delivered care: The chart must name the actual provider—no ghostwriting.
- Physician presence documented: There should be a note that the physician was on-site during the encounter.
- Ongoing plan referenced: The care plan and physician involvement should be referenced in each note.
- Co-signature not required: If you’ve met all “incident-to” rules, the physician does not need to co-sign the NPP’s note.
5. Bill Under the Right NPI
- Bill under physician’s NPI: If all rules are met, submit the claim under the supervising physician’s NPI—not the NPP’s.
- Don’t list NPP on the claim: The NPP should not appear separately on the claim for “incident-to” services.
6. Know Your State & Payer Rules
- Scope of practice matters: The NPP must perform services within their legal scope, based on your state’s law.
- Payer quirks: Some commercial payers have different interpretations of “incident-to.” Double-check their manuals.
- Example: Medicaid and some private payers may require NPP billing even with Supervision.
What You Can’t Bill as Incident To
Let’s clarify some common misunderstandings. These services do not qualify for incident to:
- New patient visits: These require a complete initial assessment and plan, which the billing physician must perform.
- New problems or symptoms: If the physician hasn’t previously addressed the issue, it can’t be an incident.
- Hospital or SNF visits: Medicare excludes these settings from incident-to provisions.
- Services performed without direct Supervision: If the physician isn’t in the office suite, billing incident to is not allowed.
Trying to “stretch” the rules often leads to audits, overpayment recoveries, and in some cases, fraud allegations.
Tips to Stay Compliant (and Paid)
1. Educate Your Staff
Host quarterly training sessions. Front desk, billing, and clinical teams should all understand the core rules. Mistakes often come from a lack of awareness, not intent.
2. Flag Eligible Encounters in EHR
Create incident to checkboxes or tags in your EHR system. This helps your billing team quickly identify what can and can’t be billed incident to.
3. Track Physician Presence
Use a simple sign-in sheet, badge log, or even a digital tool to track physician availability. This can save you in an audit.
4. Perform Regular Audits
Review 10–15 random charts monthly. Look for patterns of non-compliance before a CMS auditor does.
5. Bill Conservatively When Unsure
If there’s any doubt about compliance, bill under the NPP’s NPI. It’s better to receive 85% than risk recoupments and penalties.
Frequently Asked Questions (FAQs)
Q1: Can I bill incident to via telehealth?
No. The physician must be physically on-site. Remote Supervision doesn’t meet the direct supervision requirement under current Medicare rules.
Q2: Do commercial payers allow incident to billing?
It depends. Some private insurers follow Medicare rules, but many have their guidelines. Always verify with the payer before billing.
Q3: What happens if I bill incorrectly?
You may be subject to:
- Overpayment recovery (you’ll need to pay it back)
- Fines or penalties for fraud or misrepresentation
- Prepayment audits that delay future payments
Q4: Can a physician assistant supervise incident-to services?
No. Only a physician can supervise and bill for incident-to services. NPPs can’t supervise other NPPs under this rule.
Final Word
“Incident to” billing is a strategic tool for increasing reimbursement and optimizing clinical workflows, but it requires disciplined compliance. The 2025 Medicare guidelines continue to emphasize accurate supervision, documentation, and scope-of-practice rules.
At Medix Revenue Group, we help healthcare providers navigate complex billing regulations with clarity and confidence. If you’re unsure about proper billing practices, consult a certified coder, your MAC, or a billing compliance expert.
Don’t leave your revenue to chance, contact us today for expert guidance.
