Medicare and Mental Health Incident to Provision

Physicians and certain non-physician practitioners (NPPs) are permitted to bill ancillary services and supplies provided by auxiliary personnel “incident to” their own personal professional services.

Physicians and clinical psychologists (CPs), nurse practitioners (NPs), clinical nurse specialists (CNSs), certified nurse-midwives (CNMs), and physician assistants (PAs) can bill and be paid for certain services and supplies provided by auxiliary personnel as if they provided the services themselves if requirements are met:

• Services/supplies are integral to the patient’s normal treatment course and follow an initial service by physician or NPP to which the auxiliary personnel services are incidental.
• The auxiliary personnel provide services/supplies without charge (included in the physician’s or other listed NPP’s bill).
• Services/supplies are an expense to the physician or other listed NPP.
•  Services/supplies are commonly offered in the physician’s or other listed NPP’s office or clinic under direct supervision.

Centers for Medicare & Medicaid Services (CMS) provides an exception to direct supervision for “incident to” behavioral health services. These services, when delivered by auxiliary personnel, require only general supervision by a physician or NPP, meaning they do not need to be physically present but must be accessible if needed.

When auxiliary personnel offer services “incident to” a practitioner’s professional services, to bill Medicare they must meet any applicable requirements to provide “incident to” services, including licensure, imposed by the state in which the services are being furnished.

Pennsylvania law states “It shall be unlawful for any person to … or hold oneself out as a licensed [behavioral or mental health practitioner] without possessing a valid, unexpired, unrevoked and unsuspended license…” Act of July 9, 1987 (P.L. 220, No. 39). Providing and billing for therapy services without appropriate licensure is prohibited.

This might not be consistent with Pennsylvania Medicaid's coverage of services by auxiliary personnel. Providers are reminded to follow medical documentation standards set forth in the Provider Manual when billing services to Highmark Wholecare.

For additional information visit the Medicare’s Mental Health Coverage: Updates to Eligible Professionals.