Incident to billing pays an office visit at the physician rate, and only while the patient, the problem and the supervising practitioner line up on the same day. The office conditions have not been repealed. The definition that changed in 2024 sits next door, in the facility split or shared policy, and it is widely reported as a change to this rule. Here is where it applies, where it stops, and what the record has to show.
What this covers
- Incident to pays 100 percent of the Physician Fee Schedule under the supervising practitioner’s NPI. The same visit under the NPP’s own NPI pays 85 percent.
- It exists in noninstitutional settings. Hospital inpatient, hospital outpatient, emergency department and skilled nursing facility services cannot be billed incident to.
- The practitioner has to have personally performed the initial service and stay involved in the course of treatment. A new patient or a new problem falls outside the rule.
- The definition that changed on January 1, 2024 sits in the split or shared rule at 42 CFR 415.140, not in the office conditions at 42 CFR 410.26.
- Only the practitioner who supervised the service may bill it, and since January 1, 2026 direct supervision may be met by two way audio and video except for 010 and 090 global surgery codes.
The claim carries the supervising practitioner’s name in place of the person who did the work, so the medical record is the only place the difference can be seen.The Office of Inspector General added incident to payments to its work plan on November 15, 2024, with a report expected in fiscal year 2026.
Incident to is a payment rule. It lets Medicare pay for a service furnished by auxiliary personnel as though the supervising practitioner furnished it, at that practitioner’s rate (42 CFR 410.26). The care is the same either way. What changes is the amount: 100 percent of the fee schedule when every condition holds, 85 percent when one does not.
That 15 point spread is why the decision belongs in the schedule builder rather than in a note written after the visit. A practice that assigns a supervising practitioner by accident pays for the accident every month.
Who bills the visit, and at what rate
Two frameworks sit side by side and do not overlap. In a noninstitutional setting, any setting other than a hospital or skilled nursing facility, the incident to conditions at 42 CFR 410.26 apply. In a facility setting, a physician and a nonphysician practitioner in the same group who both work the visit fall under the split or shared rule at 42 CFR 415.140.
The rate follows the same line. A service billed under a physician’s NPI pays 100 percent of the fee schedule. Payment for a nurse practitioner’s or physician assistant’s own service is capped at 85 percent by regulation (42 CFR 414.52 and 414.56), and a service billed incident to an NPP pays the same 85 percent.
| Where the visit happens | Who bills | Rate | Claim marker |
|---|---|---|---|
| Office or clinic, place of service 11 | Incident to the supervising practitioner | 100 percent when the supervisor is a physician | Supervising practitioner’s NPI |
| Office supervised by a nurse practitioner or physician assistant | Incident to that practitioner | 85 percent | Supervising practitioner’s NPI |
| NPP works the visit alone | The NPP under their own NPI | 85 percent | None |
| Hospital inpatient, hospital outpatient, emergency department, skilled nursing facility | Split or shared, the practitioner who performed the substantive portion | 100 percent if a physician performed it, otherwise 85 percent | Modifier FS |
Modifier FS belongs to facility claims only. When CMS updated the claims processing manual for the CY2024 split or shared policy, it noted that office visits are not billable as split or shared. Teams that run medical billing services keep that mapping in the schedule, so a supervising practitioner is assigned per session and per location.
What actually changed, in 2024 and again in 2026
The definition that changed on January 1, 2024 sits in the split or shared rule for facility visits, at 42 CFR 415.140, and it is the piece most often described as a change to incident to.
Before 2024, the practitioner who performed the history, the exam or the medical decision making, or who spent more than half of the total time, could be treated as having performed the substantive portion of a split or shared visit. CMS had planned to narrow that test to time alone. The CY2024 Physician Fee Schedule final rule (CMS-1784-F, 88 FR 78818) reversed the plan and aligned the test with the 2024 CPT guidelines: more than half of the total time, or a substantive part of the medical decision making. History and exam no longer carry the visit, and critical care stays time only.
Supervision moved more recently. The CY2024 rule allowed immediate availability by real time audio and video through December 31, 2024, and the CY2025 rule made that permanent only for a narrow set of incident to services, including CPT 99211, while extending the rest through 2025. The CY2026 final rule made virtual direct supervision permanent for services that require it, except services with a global surgery indicator of 010 or 090, and CMS carried that policy in transmittal MM14315. The regulation at 42 CFR 410.26(a)(2) states it directly.
Chapter 15 section 60 of the Medicare Benefit Policy Manual, revised effective January 1, 2024, still says the practitioner must be present in the office suite and immediately available. The regulation at 42 CFR 410.26(a)(2), revised by the 2024 through 2026 rules, allows immediate availability by two way audio and video for services without a 010 or 090 global surgery indicator. Your Medicare Administrative Contractor restates the regulation in its own article. A supervisor reachable only by phone fails either version.
The conditions an office visit has to meet
The regulation lists the conditions and the manual explains the operational detail. Treat the list as one test. A visit satisfies all of it or the claim belongs under the other NPI.
- A noninstitutional setting: an office, a clinic, or any setting other than a hospital or skilled nursing facility.
- An integral, though incidental, part of the practitioner’s own service, furnished in the course of diagnosis or treatment.
- Commonly furnished without charge or included in the practitioner’s bill, and a real expense to the practice. A drug the patient bought is not covered.
- A type of service commonly furnished in the office, and not a service with its own benefit category. Diagnostic tests and vaccines follow their own rules.
- Furnished by the practitioner, by a practitioner with an incident to benefit, or by auxiliary personnel under direct supervision.
- Auxiliary personnel who meet applicable state licensure requirements.
- Billing by the supervising practitioner alone. Only the practitioner who supervised the service may bill it.
The first item that generates argument is the initiating service. The manual requires a direct, personal, professional service by the practitioner to initiate the course of treatment, and later services at a frequency that reflects continuing active participation in that course of treatment. No visit interval is published, so the practice has to show the involvement it claims.
The second is the level of the visit. An established patient office visit is reported as 99212 through 99215, chosen by medical decision making or by total time on the date of the encounter. Code 99211 describes a visit that may not require a physician, and it is the code clinical staff most often furnish here. The level still has to come from the record, and that is where most medical coding and billing reviews begin.
Where incident to stops
Almost every failure is a scheduling decision made weeks before the claim exists, not a coding decision made at the end of the month.
| The failure | What it looks like | The correct claim |
|---|---|---|
| New patient | No course of treatment exists for the visit to be incidental to | The NPP’s own NPI at 85 percent |
| New problem for an established patient | The NPP works up a complaint the practitioner never treated | The NPP’s own NPI, or the practitioner initiates it first |
| Facility setting | Hospital inpatient or outpatient, emergency department, skilled nursing facility | Split or shared there, or the NPP bills directly |
| No supervisor available | The practitioner is off site or unreachable by two way audio and video | The condition fails. Bill under the NPP |
| Wrong biller | The plan author bills while a different practitioner supervised | The supervising practitioner bills |
None of these outcomes costs the practice the entire charge. Each moves the service to the 85 percent rate or to a different rule. What it costs is the 15 point difference plus the rework, and it repeats when the same scheduling pattern recurs.
An incident to claim names the supervising practitioner as if that practitioner furnished the service. Nothing on the face of the claim tells a reviewer who performed the visit, so the Office of Inspector General added Medicare Part B Payments for Incident To Services to its work plan on November 15, 2024, under project OAS-25-01-003, with a report expected in fiscal year 2026.
The record that answers the audit
The defending file is short, and it can be assembled while the patient is still in the building rather than a year later under a document request.
Date, practitioner, the problem evaluated, and the plan of care that followed.
The note should name the plan the practitioner established and say the visit is a follow up under it.
Record who supervised, where they were, or that they were available by two way audio and video, and the window of time.
Document the total time on the date of the encounter or the medical decision making elements behind the code.
Pull incident to claims by supervising practitioner and test the failures in the table above. Fix the schedule, not the note.
Instructions vary by Medicare Administrative Contractor, so check your own. Novitas Solutions instructs practices to put the name of the practitioner who performed the initial service and ordered the nonphysician service in item 17, the supervisor’s NPI in the lower unshaded part of item 24J when the ordering practitioner is not the supervisor, and the supervisor’s signature in item 31 when someone else supervised. You can read more about MedFactor.
Behavioral health and care management run on general supervision
One part of the rule got easier. Direct supervision is the default at 42 CFR 410.26(b)(5), but designated care management services and behavioral health services furnished by auxiliary personnel incident to a practitioner’s service may be furnished under general supervision, which means the billing practitioner directs and controls the service without being present while it is furnished.
The behavioral health change arrived in the CY2023 Physician Fee Schedule final rule. The CY2024 rule extended the same treatment to rural health clinics and federally qualified health centers by revising 42 CFR 405.2413(a)(5) and 42 CFR 405.2415(a)(5), effective January 1, 2024. A counselor, care manager or community health worker can furnish a qualifying service while the billing practitioner is elsewhere, and the billing practitioner still bills for it.
One boundary matters. Incident to is a Medicare rule built on the Part B benefit and the reassignment rules, and other payers write their own. State Medicaid programs and commercial plans set their own supervision and authorization policies, and many pay a percentage of the physician rate for an NPP’s service with no incident to category at all.
Questions about incident to billing
Yes, in noninstitutional settings. A service furnished by auxiliary personnel may be billed under the supervising practitioner’s NPI when the conditions at 42 CFR 410.26 are met: an initiating service by the practitioner, continuing involvement in the course of treatment, and direct supervision. The 2024 through 2026 rules did not repeal it.
No. The rule requires a personal professional service by the practitioner to initiate the course of treatment before the auxiliary personnel’s service can be incidental to it. A new patient has no course of treatment yet. Bill it under the nurse practitioner’s or physician assistant’s own NPI at 85 percent.
Not always, since January 1, 2026. The CY2026 final rule permanently allows direct supervision through real time two way audio and video for services that require it, including incident to services under 42 CFR 410.26, except services with a global surgery indicator of 010 or 090. Audio only does not qualify.
No. Office visits cannot be reported as split or shared, because incident to payment is available in that setting. The 2024 definition of the substantive portion applies to facility visits: more than half of the total time, or a substantive part of the medical decision making. Modifier FS goes on those claims.
The service can still be payable, just not at the physician rate. Bill it under the NPP’s own NPI at 85 percent of the fee schedule, provided that practitioner is enrolled in Medicare and the service is within their scope of practice. A practitioner with no enrollment cannot have claims paid under someone else’s NPI.
Rarely in the same form. Incident to is a Medicare construct built on the Part B benefit and the reassignment rules. Commercial payers and state Medicaid programs write their own supervision and credentialing policies, and many pay a percentage of the physician rate for an NPP’s service with no incident to category. Read the provider manual first.
The person who furnished the service documents it, and the claim goes out under the supervising practitioner’s NPI. Medicare does not require the supervising practitioner to co-sign the note, and a signature is not evidence of availability. The record has to show the initiating service, the continuing involvement, and who was available.
The bottom line
Incident to billing still pays the full physician rate for work a physician’s team performs in an office, and it still asks for three things: a practitioner who started the care, a problem that practitioner already owns, and a supervisor who is available when the service is furnished. The supervision flexibility that looked temporary during the pandemic years is now permanent for everything except the 010 and 090 codes.
Which of your office visits qualify for the physician rate?
Send us one month of office visit claims with the supervising practitioner on each line, plus the matching schedule. We will test every incident to claim against the conditions in 42 CFR 410.26, mark the visits that should have gone out under the NPP’s own NPI, and point to the notes where the initiating service and the plan of care are missing. You can read how we work about MedFactor.
Request a free incident to billing reviewThis article describes Medicare Part B billing rules in force at the time of writing and general billing practice, not legal or coding advice, and commercial and Medicaid payer rules differ, so confirm the requirement in the regulation, the manual revision and your contractor’s instructions before you change how a claim is submitted.
