Incident to Quick Reference Chart
| Location | PT Status | Scenario | Who Bills | Comments |
|---|---|---|---|---|
| Office | New patient | NPP sees patient - MD not present in office suite | NPP bills for the service under the NPP NPI | NPP documents full office visit |
| Office | New patient | MD sees patient, with some participation by NPP or clinical staff | MD bills for the service under the MD NPI | NPP can document ROS, PFSH, vitals. Incident to concept does not apply for initial office visits. |
| Office | Established patient | NPP sees patient - MD not present in office suite | NPP bills for the service under the NPP NPI | Incident to requirement not met if MD not immediately available to NPP |
| Office | Established patient | NPP sees patient (no new problems); MD immediately available in office suite for supervision if needed | Service may be billed under MD's NPI. MD must see the patient periodically and document MD involvement and oversight of care | Incident to rules apply in this scenario |
| Office | Established patient | NPP sees patient; no change in Pt condition; MD documents their contribution to visit which must include F2F care | Service may be billed under the MD's NPI | NPP & MD document individual contribution(s) to care |
| Office | Established patient | NPP sees patient who presents with new or worsening problem | Service may be billed under MD's NPI, only if MD sees patient and documents participation; otherwise, service billed by NPP | NPP & MD document individual contribution(s) to care |
| Hospital (Inpatient Outpatient ER Observation) | Initial or subsequent care | NPP and MD "split/share" the visit and each performs a F2F component | MD must participate and perform and document more than 50% of the time or substantive portion of the MDM | Split/Shared rules apply in the hospital setting |
| Hospital (Inpatient Outpatient ER Observation) | Initial or subsequent care | MD Collaborates with NPP but MD does not have face to face with the patient. | NPP bills with NPP NPI | NPP & MD document contribution(s) F2F MD care required to bill with MD's NPI |
| Hospital (Inpatient Outpatient ER Observation) | Initial or subsequent care | NPP sees patient without MD participation or collaboration | NPP bills with NPP NPI | NPP documents full service |
| Consultative Services: Split/Shared concept does not apply | N/A | N/A | N/A | Consultative services must be performed exclusively by the billing provider |
Revised 8/5/2024