Office of Inspector General (OIG) Workplan now includes “Incident-to” Services

The OIG work plan set forth audits and evaluations currently underway, planned in the near future, or to be addressed by various government agencies, including the Centers for Medicare and Medicaid Services.

In November 2024, the OIG added “Incident-to” services to the work plan. If you are reporting advanced practice providers under a physician’s NPI number in your practice, we recommend that you audit these services to ensure you meet the criteria. The objective of the OIG is to audit and determine whether Medicare Part B payments for these services meet the Medicare guidelines.

Advance Practice Providers include:

· Physician Assistant (PA)

· Nurse Practitioner (NP)

· Clinical Nurse Specialist (CNS)

· Other terminology for qualified practitioner – Advanced Practice Registered Nurse (APRN), Advanced Certified Nurse Practitioner (ACNP)

· CPT refers to PAs, NPs, and CNSs as Qualified Health Professionals (QHPs).

Medicare Guidelines for “Incident-to”

1. Incident to” applies only to services provided in place of service (POS) - physician office (11)

You cannot report “incident to” in the following locations:

· Hospital outpatient department or clinic (HOPD, 19 or 22),

· Hospital inpatient (POS 21)

· Emergency department-hospital (POS 23)

2. The APP must be an employee or contractor of the physician/practice.

3. The physician must have performed an initial service (at a prior date) and developed a care plan. Services can then be delivered “incident to” this plan.

a. The patient must be an established patient with an established problem.

b. If the APP sees a new patient, he/she must bill using his/her own NPI number.

c. c. If the patient presents with a new or worsening problem and the plan of care changes, the APP cannot report “incident-to.” The service can be billed using the APP’s NPI number.

4. The physician must continue actively participating in the patient’s care.

5. Although Medicare does not require the physician to sign the note, it is recommended that he/she be indicated in the office at the time of the visit. KZA recommends that the physician, at a minimum, review notes billed as “incident to” since the physician is responsible for the claim.

A billing/supervising physician must be immediately available in the office suite. This physician does not need to be the physician who developed the plan of care.

KZA Recommendations for Ensuring Compliance

1. Review a sample of APP billing and documentation and consider co-signing the E/M notes.

2. Provide training for APPs, coders, and billing staff on “Incident-to” guidelines.

3. Proactively audit services billed as “Incident-to” to ensure compliance with Medicare rules.

Taking these steps will help your practice meet the necessary guidelines and avoid potential issues during OIG audits.