The purpose of the "Incident to" self-service tool is to assist providers with understanding
the CMS Part B "incident-to" requirements and to apply the rules to their individual
given patient/provider circumstances and to understand documentation requirements
Use of this tool is not a guarantee of coverage nor meant to imply coverage, but
rather is intended to be a tool to assist providers in understanding coverage criteria
and applying that criteria based on self-reported circumstances of a given patient
encounter. Medicare will continue to require that all documentation and coverage
requirements are met.
1) Is this a new patient, OR a new problem for an established patient?
2) Does the person performing the service meet the definition of auxiliary
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
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.
3) Is the service being provided in place of service 22 (outpatient hospital), 19
(off campus outpatient hospital) or 23 (emergency department)?
4) Is the patient being seen in a NF (nursing facility) or SNF (skilled nursing
4a) Were the services performed in a section of the facility that meets the definition
of an office?
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.
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?
7) Does the patient's medical records support continued involvement by the physician
who initiated the plan of care?
8) Does the documentation for service(s) billed include the date and legible signature
of the rendering provider?