Current through Register 2024 Notice Reg. No. 38, September 20, 2024
(a) Non-institutional Setting.
For purposes of this section a non-institutional setting
means all settings other than a hospital or skilled nursing facility.
(1) Services that are furnished incident to a
physician's are commonly included in the physician's bills, and for which no
separate payment is made. Diagnostic tests and pneumococcal, influenza, and
hepatitis B vaccines need not also meet the incident to requirement in this
section.
(2) NPPs may provide
services without direct physician supervision and bill directly for these
services. When their services are provided under direct physician supervision,
their services may be covered as incident to services, in which case the
incident to requirements would apply.
(3) To be covered incident to the services of
a physician, services must be:
(A) An
integral, although incidental, part of the physician's professional
service;
(B) Commonly rendered
without charge or included in the physician's bill;
(C) Of a type that are commonly furnished in
physician's offices or clinics;
(D)
Furnished by the physician or by auxiliary personnel under the physician's
direct supervision.
(b) Institutional Setting.
Hospital services incident to physician's services
rendered to outpatients and partial hospitalization services incident to such
services are subject to the incident to requirements. Payment for these
services is made to a hospital.
(c) Incident To Physician's Professional
Services
Incident to a physician's professional services means
that the services are furnished as an integral, although incidental, part of
the physician's personal professional services in the course of diagnosis or
treatment of an injury or illness. See section
9789.19 for "incident to" codes by
date of service.
(1) Services Commonly
Furnished in Physicians' Offices.
Services commonly furnished in physicians' offices are
covered under the incident to provision. Charges for such services must be
included in the physicians' bills. Where services are of a type not considered
medically appropriate to provide in the office setting, they would not be
covered under the incident to provision.
(2) Direct Personal Supervision.
(A) Services incident to the professional
services of a physician in private practice is limited to situations in which
there is direct physician supervision of auxiliary/NPP personnel. The incident
to services must represent an expense incurred by the physician or legal entity
billing for the services.
(B) Where
a physician supervises auxiliary/NPP personnel to assist him/her in rendering
services to patients and includes the charges for their services in his/her own
bills, the services of such personnel are considered incident to the
physician's service if there is a physician's service rendered to which the
services of such personnel are an incidental part and there is direct
supervision by the physician.
(C)
To be considered incident to, each occasion of service by auxiliary/NPP
personnel needs also to always be the occasion of the actual rendition of a
personal professional service by the physician. Such a service could be
considered to be incident to when furnished during a course of treatment where
the physician performs an initial service and subsequent services of a
frequency which reflect his/her active participation in and management of the
course of treatment. However, the direct supervision requirement must still be
met with respect to every non-physician service.
(D) Direct supervision in the office setting
does not mean that the physician must be present in the same room with his or
her aide. However, the physician must be present in the office suite and
immediately available to provide assistance and direction throughout the time
the aide is performing services.
(E) If auxiliary/NPP personnel perform
services outside the office setting, e.g., in a patient's home or in an
institution (other than hospital or skilled nursing facility (SNF)), their
services are covered incident to a physician's service only if there is direct
supervision by the physician. For example, if a nurse accompanied the physician
on house calls and administered an injection, the nurse's services are covered.
If the same nurse made the calls alone and administered the injection, the
services are not covered (even when billed by the physician) since the
physician is not providing direct supervision.
(F) The availability of the physician by
telephone and the presence of the physician somewhere in the institution does
not constitute direct supervision for services provided by auxiliary/NPP
personnel in an institution (e.g., nursing, or convalescent home).
(G) There is no payment for services of
physician-employed auxiliary/NPP personnel as services incident to physician
service.
(H) A NPP who performs a
specific medical procedure without physician supervision may receive separate
payment for the service as a NPP's service.
(d) Incident to physician's services in
clinic.
Services incident to a physician's service in a physician
directed clinic or group association are generally the same as those described
in this subsection.
A physician directed clinic is one where:
(1) A physician (or a number of physicians)
is present to perform medical (rather than administrative) services at all
times the clinic is open;
(2) Each
patient is under the care of a clinic physician; and
(3) The non-physician services are under
medical supervision.
(4) In highly
organized clinics, particularly those that are departmentalized, direct
physician supervision may be the responsibility of several physicians as
opposed to an individual attending physician. In this situation, medical
management of all services provided in the clinic is assured. The physician
ordering a particular service need not be the physician who is supervising the
service.
(5) When the auxiliary/NPP
personnel perform services outside the clinic premises, the services are
covered only if performed under the direct supervision of a clinic physician.
If the clinic refers a patient for auxiliary/NPP services performed by
personnel who are not supervised by clinic physicians, such services are not
incident to a physician's service.
1. New
section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and
print only pursuant to Government Code section 11340.9(g) (Register 2013, No.
39).
Note: Authority: Sections
133, 4603.5, 5307.1 and 5307.3,
Labor Code. Reference: Sections
4600, 5307.1 and 5307.11, Labor
Code.
