Can a service be billed as 'incident to' if the auxiliary staff performing the service, where there is no face-to-face encounter with the billing provider, changes a patient's treatment plan based on protocol or the results of laboratory tests?

Answer: No. This does not mean that each occasion of an incidental service performed by a nonphysician practitioner must always be the occasion of a service actually rendered by the physician. It does mean that there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician's continuing active participation in and management of the course of treatment.

The following situations would be considered to represent a change or modification in treatment plan and would therefore not meet the incident to requirements.

  • Change in treatment plan regardless of protocol or lab tests results including changes from the original plan/order related to:
    • Frequency of services
    • Duration
    • Dosage
    • Drugs or biological administered
    • Administration method
    • Orders for diagnostic tests
    • Treatment of new problems

Reference: CMS Internet Only Manual Publication 100-2, Chapter 15, Section 60.2 (PDF, 1.29 MB).

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