“Incident to Billing” for Therapy Services
Lately, I have been receiving several questions regarding “incident to billing” for outpatient therapy services provided in the private practice setting. Essentially, can the services of a physical therapist (PT), occupational therapist (OT) or speech-language pathologist (SLP) be billed incident to a physician or a nonphysician practitioner (NPP) in the private practice setting? Also, people want to know if the services provided by a physical therapist assistant (PTA) or occupational therapy assistant (OTA) can be billed incident to a physician or NPP in the private practice setting? In this article, I will answer both questions as they pertain to Medicare outpatient therapy services and private insurance carriers.
Regarding Medicare outpatient therapy services, the services provided by a PT, OT and/or SLP in a private practice can
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Am I understanding correctly? In an outpatient private practice, even if there is a physician and PT onsite, a PTA still should not treat and bill incident-to according to Medicare?
Services provided by a PTA can’t be billed under the physicians NPI as “incident-to” billing.
Rick,
What if the hospital owns the physician clinic that the physical therapist practices in? In this scenario can the physical therapist practice and bill for his/her services?
If the hospital owned clinic is set up as a private practice, meaning you submit claims on a 1500 claim form, then the billing is done under the individual PTs NPI number or the PT could have their services billed “incident-to’ the physician if all the guidelines are met.
Rick – Can a PT/OT,while waiting to be credentialed by insurance carriers, bill incident to another PT/OT if that therapist is in the office and signs off on the medical record?
You would have to check with that insurance carrier to see if they allow it.
Hi Rick,
If an office bills incident to the physician, but the physician ends up sick or something happens that takes them out of the office, would therapists need to cancel patients, or could they “switch” to billing under the therapist for that one visit and continue back to “incident to physician” upon next treatment?
If the therapist was a credentialed provider with that insurance carrier, you would bill for that visit under the therapists NPI number. To be honest with you. why would you not want to do that on all of your visits.
I honestly do not know why that is a practice. Is the reimbursement different? We are at the mercy of what the MDs want.
The Medicare program pays the same rate whether billed incident to a physician, under the NPI number of a therapist, or the NPI number of a facility. There are some private insurance carriers that do pay a higher rate if billed under the physicians NPI number compared to billing under the therapists NPI number.
May a PT employed in an “incident to” Physician practice, although billing under her/his own NPI recruit and treat patients referred by an outside physician, who is outside and not part of the practice wher therapy services are provided?
This example sits within a privately owned MD practice, within a hospital organization, where the docs, who employ PT/OT, but where outside physicians would like to refer their patients, given the proximity and knowledge of the providing therapist, who work for docs, who own the practice.
This would be an issue you want to discuss with your healthcare attorneys.
Rick,
We have moved to provider based billing and have specific contracts per payer, whether they accept the facility fee or not. We would like to see if we can bill our therapy as incident to, drop the charges on our professional claim, POS 22, and not worry about the facility bill for those carriers that will not cover. Is this acceptable under Medicare’s guidelines? I have reviewed the Medicare Benefit Policy Manual and section 230.5 doesn’t really cover the POS that is acceptable for incident to for therapy. 230.6 states that the therapy must be billed on a facility claim; however, no mention to incident to. Can you shed some light on this for us?
Thank you
Due to liability reasons, this is not something I can answer in this forum. If you would like consulting services to address this issue, please contact me at info@gawendaseminars.com
Hi Rick. We have recently had more than one Medicare patient tell us they are going to a physician owned therapy practice for therapy because they are billed less there than when they see us. They state they pay a $30 co-pay every visit. How can this be? Don’t physician owned practices have to bill the individual CPT codes like we do, and isn’t the reimbursement rate based on the MPFS for all providers as indicated in your August 2017 answer above? I find it hard to believe all services would magically come out to a flat $30 every time.
Thanks
The Medicare Part B program pays physician owned therapy clinics the same Medicare allowed amount for each CPT code as they do for private practices owned by a therapist or a nonprivate practice assuming you are all in the same locality.
Can a PT/OT,while waiting to be credentialed by Medicare, bill incident to another PT/OT if that therapist is in the office and signs off on the medical record?
Yes
Does a PT treating under “incident to” and billing under the physician’s NPI have to perform and bill a PT evaluation in order to treat? I am thinking of having a manual based PT available on site to assess and manually treat a patient on their first physician visit (i.e back pain patient that would benefit from a mobilization/manipulation). I think it would be a great initial ancillary service but I also want to respect the patient by not having to bill a PT eval or collect a separate copay if possible.
Per their PT practice act, they most likely would be required to perform an evaluation prior to implementing treatment.
Hey Rick – in relation to the example above – a PT (billing incident to) AND the physician perform services on the SAME DAY: will there be any reimbursement issues? I have heard that only one of the providers would get paid. Thanks for your insight!
It would depend if billed under the same group number. If yes, then you would have to check with the specific insurance carrier. If different provider numbers, then should not be an issue, but always your responsibility to check.
Does a PT practicing “incident to physician services” need to have his or her POC on file in the medical chart signed by the physician to qualify for Medicare reimbursement? We are completely reformatting our EMR and your answer will help with that project.
Physicians must sign and date a therapy plan of care for outpatient therapy services.
I am a PT billing “incident to physician services”. Does the POC I set up and keep on file in the medical chart require e-signature by a practice physician for Medicare reimbursement? We are reconfiguring our office EMR and your answer will help.
Physicians must sign and date a therapy plan of care for outpatient therapy services.
Hello,
just clarifying that a non-credentialed but licensed PT can bill under a credentialed PT as long as the supervisory language is met and the note is cosigned by the credentialed PT? Is that accurate?
thank you much,
Aaron
It would be insurance carrier specific, but generally, the answer is no as most insurance carriers require each therapist to get credentialed.