incident-to-billing-policy

name	incident-to-billing-policy
title	Incident-To Billing Policy
description	Drafts Medicare incident-to billing compliance policies for healthcare practices. Covers eligibility criteria, direct supervision, documentation standards, audit programs, and FCA risk mitigation under 42 CFR 410.26, Medicare Benefit Policy Manual Ch. 15 §60.1, and 42 U.S.C. §1395x(s)(2)(A). Use when creating or updating incident-to policies, responding to OIG scrutiny, or establishing NPP billing compliance programs.
author	CaseMark
author_url	https://github.com/CaseMark/skills/tree/main/skills/legal/incident-to-billing-policy
license	Apache-2.0
version	0.1.0
execution_mode	open
jurisdiction	us
practice	healthcare
language	en

Incident-To Billing Policy

Drafts a compliance policy governing Medicare incident-to billing — NPP services billed under the supervising physician's NPI at the physician rate. Improper use creates False Claims Act liability, civil monetary penalties, and program exclusion risk.

Prerequisites

Gather before drafting:

1. Practice profile — specialties, locations, states of operation
2. Provider roster — supervising physicians and NPPs (NPs, PAs, CNSs) with credentials
3. Existing policies — current billing policies, EHR workflows, prior audit findings
4. State scope-of-practice rules — per operating state (stricter state rules override Medicare)
5. Payer scope — Medicare only or also Medicaid/commercial (rules vary by payer)

Quick Start

Core question for every encounter: Does this visit meet all nine eligibility criteria? If any criterion fails, bill under the NPP's own NPI.

Policy Drafting Workflow

1. Policy Header

Include: effective date, annual review cycle, scope (all clinical/billing staff), and governing authority (42 CFR 410.26; Medicare Benefit Policy Manual Ch. 15 §60.1; 42 U.S.C. §1395x(s)(2)(A)). State that incident-to is a conditional billing privilege with FCA consequences for misuse.

2. Key Definitions

Term	Definition
Incident-To Billing	Billing NPP services under supervising physician's NPI at physician rate
Direct Supervision	Physician physically present in office suite and immediately available — phone/telehealth does NOT qualify
NPP	Non-physician practitioner (NP, PA, CNS, CNM) per Medicare definition
Initial Service	First physician evaluation establishing diagnosis and treatment plan

3. Eligibility Criteria (All Required)

• Physician personally performed the initial service for the condition
• Physician established and documented a treatment plan
• Physician remains actively involved in ongoing management
• Service is a to the plan — not a new problem or diagnosis