Billing and Coding: Incident To Clarification for OPPS and CAH Outpatient

Medicare will reimburse outpatient hospital services provided personally by eligible practitioners (MD, NP, PA) or by hospital personnel 'incident to' an eligible practitioner when strict conditions are met: services must follow an initial practitioner encounter, be integral/incidental to that professional service, follow a valid signed order (42 CFR §482.12(c)), and be rendered under a physician supervisor who is an employee/contractor and immediately available on the hospital premises. There is no incident-to coverage in the inpatient setting, and supervising physicians/NPPs may not bill for hospital employee services — only the hospital may bill for those services.

"Medicare may reimburse outpatient hospital services personally delivered by eligible practitioners (physician/MD, nurse practitioner/NP, or physician assistant/PA)."

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