Incident-To Billing Checker
Can this service be billed under the physician at 100% of the Medicare fee schedule — or does it belong under the NPP's own NPI at 85%? Answer five questions and get a clear answer with the reasoning.
"Incident-to" is one of the most misused concepts in Medicare billing. Under Medicare's incident-to rules, services furnished by non-physician practitioners (NPPs) or auxiliary staff can sometimes be billed under a supervising physician's NPI and paid at 100% of the physician fee schedule instead of the 85% paid under the NPP's own NPI. The catch: every requirement has to be met — established patient, an established plan of care, direct supervision, scope of practice, and an employment or contractual relationship. Miss one, and the claim is billed wrong. This checker walks through each requirement in turn.
Check an incident-to scenario
Step 1 of 6
The answer changes which billing options exist if a requirement fails.
The five Medicare incident-to requirements
- Established patient — the patient has been seen before by the physician (or a same-specialty physician in the group). Incident-to never applies to a first visit.
- Established plan of care — the physician initiated the treatment plan for this problem and remains actively involved. A new problem needs the physician's own evaluation first.
- Direct supervision — the physician is physically present in the office suite and immediately available while the service is furnished.
- Scope and state law — the service is within the performer's scope of practice and permitted under state law.
- Employment relationship — the performer is an employee, leased employee, or contractor of the physician or practice.
Two important boundaries. First, incident-to is an office-setting concept: it does not apply to services furnished in a hospital inpatient or hospital outpatient department. Second, split/shared visits — where a physician and an NPP in the same group share an E/M visit, most often in a facility — follow a different CMS rule set with its own documentation and billing-provider rules; do not run those visits through this checker. Commercial payers and Medicaid plans also set their own incident-to and supervision policies, which may be stricter or looser than Medicare's — the Medicare analysis above does not carry over automatically. Getting the rendering provider wrong is a quiet, repeat-error: our medical coding support team audits incident-to claims for exactly these failures.
Disclaimer: This checker is educational only. It is not medical, legal, or billing advice for a specific case, and it does not guarantee coverage or payment. Incident-to and supervision rules change and vary by payer and setting; verify the current rule with CMS, your Medicare Administrative Contractor, or the payer before billing.
Frequently asked questions
What does incident-to mean in Medicare billing?
Incident-to describes services furnished by NPPs or auxiliary staff that are an integral part of a physician's treatment of an established patient, furnished under the physician's direct supervision in the office. When every requirement is met, the service is billed under the physician's NPI and paid at 100% of the physician fee schedule instead of the 85% NPP rate.
Can incident-to be used for a new patient or a new problem?
No. The physician must have seen the patient before and established the plan of care for the problem being treated. A new patient, or an established patient presenting with a new problem the physician has not evaluated, must be seen by the physician personally (or billed under the NPP's own NPI) before incident-to can apply to later visits.
What is the difference between incident-to and a split/shared visit?
Incident-to is an office-setting rule for services by staff under a physician's direct supervision, billed under the physician. A split/shared visit is a facility-setting E/M visit shared between a physician and an NPP in the same group, billed under whichever of them performed the substantive portion under CMS's current rules. The requirements, documentation, and billing provider differ — they are not interchangeable.
Does incident-to apply in the hospital?
No. Incident-to does not apply in hospital inpatient or hospital outpatient departments. Services there follow the facility billing rules, including the split/shared visit rules for shared E/M services.