GUIDANCE FOR “INCIDENT TO” BILLING UNDER CENTER FOR MEDICARE &MEDICAID SERVICES (CMS)
- HC Intellect
- 1 day ago
- 7 min read
Memo
To: All Providers
From: Medical Coding Department
Date: February 1st ,2026
Subject: Guidance for “Incident to” Billing under Center for Medicare & Medicaid Services (CMS)
Bottom Line
If the visit involves anything new - a new symptom, diagnosis, medication, imaging order, or procedural decision - it invalidates incident-to. Incident-to billing is allowed only when an NPP follows a specific, physician-established plan of care under direct supervision, without independent clinical judgment. When in doubt, bill under the NPP.
Definition & Overview:
“Incident to” services are furnished as an integral but incidental part of a physician’s or eligible practitioner’s professional services. New patient visits cannot be billed incident-to.
A non-physician (auxiliary staff or NPP) may provide the service, but billing may be done under the supervising provider’s NPI when all criteria are met.
Full compliance is required to avoid improper billing.
Where Incident-To Applies
Noninstitutional settings (e.g., physician offices, clinics)
Does not apply in:
Hospitals
Skilled Nursing Facilities (SNFs)
Certain institutional settings unless specific conditions are met
Who Qualifies as the “Physician”
Physicians (MD/DO)
Physician Assistants
Nurse Practitioners
Clinical Nurse Specialists
Certified Nurse Midwives
Clinical Psychologists
These providers can supervise and can also have incident-to services billed under their NPI (if appropriate).
SECTION 1 — Supervisory Requirements (Direct Supervision)
Medicare defines “direct supervision” very specifically:
1. The Supervising Physician Must Be Physically Present in the Office Suite
The physician must be on-site, not remote.
They must be immediately available to assist the NPP.
Being “in the building” is not sufficient if they are not available (e.g., in a separate area, unavailable due to meetings, off-site for lunch).
2. The Supervising Physician Must Be Able to Manage the Patient’s Care
The supervising physician must be part of the same group.
While they do not have to be the physician who originally created the plan of care, the practice must demonstrate continuity of care within the group.
SECTION 2 — New Problems & New Clinical Decisions (Why They Break Incident-To)
Incident-to only applies when the NPP is continuing an established physician-created plan of care. The following situations invalidate incident-to:
1. A New Problem Emerges
Examples:
New anatomical pain (shoulder, hip, knee)
Change in pain pattern (radicular → axial, axial → SI joint)
New neurological deficit
Functional decline not covered in the original plan
→ A physician must evaluate the new condition and update the plan before NPPs can resume incident-to billing.
2. A Significant Change in the Treatment Plan Is Required
If the NPP needs to:
Order a new intervention (ESI, MBB, RFA, SIJ injection, etc.)
Initiate a new medication not contemplated in the plan
Add or change diagnosis codes
Refer out for a newly emerging condition
→ These decisions represent a new plan of care, which cannot be billed incident-to.
3. Medication Changes Can Break Incident-To
Not all medication adjustments invalidate incident-to—only when they fall outside the physician’s documented plan.
Examples of changes that do break incident-to:
Starting opioids when opioid therapy was not included in the plan
Switching neuropathic agents (gabapentin → pregabalin) without physician authorization
Adding new drug classes (muscle relaxants, antidepressants) not contemplated in the plan.
SECTION 3 — Broad Multimodal Plans (Why They Fail in Pain Management Audits)
Many pain physicians document a generic, catch-all multimodal approach, such as:
“We will manage with multimodal therapy including PT, medications, ESI for radicular pain, MBB for axial pain, RFA as needed, and other interventions if clinically appropriate.”
Medicare auditors routinely flag this because:
1. The Plan Is Too Broad to Demonstrate Physician Direction
A compliant plan must indicate:
A specific diagnosis
A specific set of interventions
A specific rationale
Broad, open-ended plans appear to authorize future independent decision-making by the NPP.
2. It Appears to Delegate Treatment Selection to the NPP
When multiple procedures are listed as future possibilities, CMS may conclude:
“The NP/PA is independently determining which intervention to pursue.”
This violates the core incident-to requirement:
NPPs cannot independently diagnose, design treatment pathways, or create new plans of care under incident-to.
3. Plans Must Anticipate Titration but Not Open-Ended Intervention Choices
Medication titration and follow-up visits can be pre-authorized, but decisions such as “ESI vs MBB vs RFA vs SIJ” require fresh physician evaluation.
4. Pain Patterns Evolve and Require Physician Reassessment
Pain often shifts:
• Radicular → Axial
• Axial → SI joint
• Lumbar → Hip
• Neuropathic → Mechanical
A broad multimodal plan does not extend to newly emerging pain generators and cannot serve as standing authorization for NPP procedural decision-making.
SECTION 4 — Ordering Diagnostic Imaging (MRI, X-ray, CT, EMG) and Incident-To Compliance
Ordering diagnostic tests can break incident-to because Medicare views the act of ordering imaging as:
A clinical decision that typically requires physician involvement, unless the order is explicitly included in the physician’s original plan of care.
To stay compliant, here’s how to think about imaging.
1.Ordering Imaging Is Usually Considered a New Clinical Decision
MRI, X-ray, CT, and EMG orders typically mean:
The patient has a new symptom,
A worsening condition, or
The provider is evaluating a new differential diagnosis.
Medicare interprets this as new diagnosis + new plan of care, which cannot be billed incident-to.
So, if an NP/PA orders imaging without the physician having established that as part of the plan, the visit must be billed under the NPP’s NPI (85%), not the physicians.
2.When Imaging Can Be Ordered Incident-To
Imaging is allowed only if the initial physician plan of care explicitly authorizes it, such as:
“If pain persists despite conservative treatment, order MRI of lumbar spine to evaluate for disc herniation or other pathology.”
or
“If radicular symptoms continue, obtain EMG/NCS.” When this language exists and the imaging request directly matches the condition in the plan, an NPP may order the test and still bill incident-to.
3. When Imaging Automatically Breaks Incident-To
Any of the following requires billing under the NP/PA’s NPI:
MRI/X-ray is ordered for a new pain location (e.g., patient previously managed for lumbar pain now has hip or knee pain)
Imaging is ordered due to a change in pain pattern (axial → radicular, radicular → axial)
Imaging is ordered because of new symptoms (weakness, numbness, falls, bowel/bladder issues)
Imaging is ordered where no prior plan anticipated diagnostic testing
The NPP orders an MRI/CT to rule out new differential diagnoses
These reflect new problem evaluation, not continuation of care.
4. What Auditors Say About Imaging Under Incident-To
Medicare MACs have written repeatedly:
“Ordering diagnostic tests typically represents a new physician-level service unless the test was explicitly authorized in the plan of care.”
This means generic multimodal plans do NOT cover imaging orders.
5. Example Scenarios
Example A — Imaging Allowed Under Incident-To
Original physician plan:
“If radicular symptoms persist after PT, obtain MRI lumbar spine.”
NPP visit:
Radicular symptoms unchanged → MRI ordered.
✔ Incident-to allowed
✔ Plan covers the decision
✔ No new diagnosis was created
Example B — Imaging NOT Allowed Under Incident-To
Original physician plan:
“Manage with multimodal pain control.”
NPP visit:
Patient now reports groin pain → NP orders hip MRI.
❌ Not incident-to
❌ New pain generator
❌ New diagnostic decision
❌ Must bill under NP NPI
Example C — Imaging NOT Allowed Under Incident-To
Original physician plan:
“Manage lumbar facet-mediated pain.”
NPP visit:
Patient now has leg numbness → NP orders EMG.
❌ New neurologic symptom
❌ New differential
❌ Outside plan
❌ Not incident-to
SECTION 5 — CMS Signature Requirements for Incident-To Services
Signature requirements arise from CMS’s general documentation rules and are separate from incident-to billing rules. CMS signature requirements are addressed in the Medicare Program Integrity Manual (Pub. 100-08, Chapter 3, §3.3.2.1). CMS requires that medical records be authenticated by the author of the service.
CMS Verbatim Citation – Signature Requirement
“The medical record must be authenticated by the author. Authentication may include signatures, initials, or an electronic signature and must identify the individual who documented the service.”
— Medicare Program Integrity Manual (Pub. 100-08), Chapter 3, §3.3.2.1
For incident-to encounters, the NP or PA is the individual who rendered and documented the service and is therefore required to sign the note. A supervising physician co-signature does not replace this requirement unless otherwise mandated by state law or payer contract.
Footnotes / Source Separation
Incident-To Billing Rules: Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15 – Defines supervision, plan of care, and billing eligibility for incident-to services.
Signature & Authentication Rules: Medicare Program Integrity Manual (Pub. 100-08), Chapter 3, §3.3.2.1 – Defines who must authenticate (sign) the medical record.
PROVIDER TAKEAWAY: “If you rendered it, you must sign it.”
CMS-Compliant Sample Medical Record Statements
Incident-To Compliance Statement:
I, [Name], [NP/PA], am providing services today under the direct supervision of Dr. [Physician Name], who is physically present in the office suite and immediately available for assistance. The patient’s evaluation and management today are being performed strictly in accordance with the established plan of care created and initiated by Dr. [Physician Name] on [date]. The conditions addressed during this encounter were included in the original plan, which authorized ongoing medication titration, procedure follow-up, and related management as clinically indicated. There has been no deviation, expansion, or initiation of new diagnoses or treatment plans. This service meets all Medicare “incident-to” requirements, including direct supervision, established patient status, continuity of care, and provision by an employee/contractor of the physician’s practice, and is therefore billed under the physician’s NPI.
— End of Memo —
HC Intellect is a Milwaukee-based healthcare revenue cycle management (RCM) and technology firm with a deep specialization in interventional pain management and related surgical specialties. The company partners closely with pain practices and ASCs to optimize coding, billing, and collections across the full revenue cycle, with particular expertise in complex procedure coding, E&M optimization, and payer-specific reimbursement challenges unique to interventional pain. By combining experienced RCM teams with proprietary analytics and AI-driven tools, HC Intellect helps pain practices reduce denials, accelerate cash flow, and sustainably improve financial performance.
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