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Learn The Lingo

Learn the Lingo: Key Terms for Navigating the Value Based Care World

With the shift toward value-based payment models, pharmacists are seizing new opportunities to improve patient care in medical homes, accountable care organizations, and other innovative care models. This resource includes acronyms and terminology commonly used when practicing in or discussing innovative practice models. Each term includes a short description and references so you can further your practice in a value based care world. This is the first of multiple volumes that will be published by the Medical Home/ACO SIG.

Shruthi Gowda
/ Categories: Learn the Lingo

Incident to Services

Definition: “Incident to” services are defined as services that are furnished as an integral, although incidental, part of a physician’s professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.1,2 In the Medicare program administered by the Centers for Medicare and Medicaid Services (CMS), auxiliary personnel such as pharmacists; nurses; and nonphysician practitioners (NPPs) like physician assistants, nurse practitioners, or clinical nurse specialists can provide some services traditionally performed by physicians in certain practice settings under incident to services arrangements.1,2 These services must be part of a patient’s normal course of treatment and are billed by the CMS-recognized provider under that provider’s National Provider Identifier (NPI).1,2

By allowing NPPs and auxiliary personnel to collaborate and provide incident to services, Medicare can reduce costs and improve patients’ access to the health care system.2 Though incident to billing most commonly occurs within the Medicare program, some Medicaid and commercial payers also permit incident to billing. However, requirements to utilize incident to billing varies among these plans.

Incident to billing allows auxiliary personnel and NPPs to report services as if they were performed by a physician. Additionally, there are specific requirements to bill incident to services. Specific incident to requirements include3–7

  • Pharmacists must be contracted with, leased to, or directly employed by a Medicare Part B–approved physician or organization with whom they are collaborating.
  • Services provided by a pharmacist must be within the pharmacist’s scope of practice as dictated by the state’s pharmacy practice act.
  • Services must be a necessary part of a patient’s normal course of treatment.
  • NPPs that are CMS-recognized providers can also serve as the incident to provider and bill for the services of auxiliary personnel such as pharmacists. (Note that in the Medicare program, NPPs can bill Medicare directly at 85% of the physician’s rate.)
  • The patient must first be seen by the physician for an evaluation prior to any incident to services.
  • Subsequent services provided by auxiliary personnel or NPPs must be conducted under direct supervision, which is defined as the physician or collaborating provider being physically present in the office suite or building (depending on the practice setting) and immediately able to provide assistance, if needed.
    • Effective June 2020, CMS revised the definition of direct supervision to allow direct supervision to be provided using real-time interactive audio and video technology for the duration of the public health emergency for the COVID-19 pandemic.
  • Collaborating providers must continue to see the patient at a frequency that reflects their active participation in the management of the course of treatment.

How it relates to patient-centered medical homes: Although pharmacists are not considered NPPs, their services can still be billed as incident to services for both fee-for-service models and value-based payment structures like transitional care management and chronic care management programs.5 With the ability for physicians to bill for pharmacists’ services under incident to arrangements, there is greater opportunity for interdisciplinary collaboration between pharmacists, physicians, NPPs, and other members of the health care team. This collaboration can lead to more comprehensive patient-centered care and improved patient outcomes.

Involved organizations/oversight: CMS directly controls the regulations for incident to services in the Medicare program. State Medicaid and commercial insurance plans that provide coverage using incident to arrangements often mirror their requirements to match the Medicare program, although this is not always the case.5

Resources:

  1. Medicare Learning Network. “Incident to” Services. CMS. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf
  2. Noridian Healthcare Solutions. Jurisdiction E - Medicare Part B: Incident To Services. February 2020. Available at: https://med.noridianmedicare.com/web/jeb/topics/incident-to-services
  3. Medicare Learning Network. Transitional Care Management Services. MLN908628 July 2021. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf
  4. APhA. Chronic care management (CCM): An overview for pharmacists. 2017 Mar. APhA: American Pharmacists Association. https://www.pharmacist.com/Portals/0/PDFS/Practice/CCM-An-Overview-for-Pharmacists-FINAL.pdf. Accessed February 12, 2022.
  5. APhA. Billing Primer: A Pharmacist’s Guide to Outpatient Fee-for-Service Billing. Washington, DC: American Pharmacists Association; August 2019. Available at: https://www.pharmacist.com/Practice/Practice-Resources/Billing-Payment-Center
  6. Medicare Learning Network. Chronic Care Management Services. ICN MLN909188 July 2019. Available at: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf
  7. HHS. CMS Manual System. Pub 100-20 one-time notification. CMS.gov. https://www.cms.gov/files/document/r10160otn.pdf

Contributing authors:

Jordan Rowe, PharmD, BCACP, BC-ADM
Chair, 2021-2023 APhA-APPM Pharmacy Residency Standing Committee
New Practitioner Officer, 2021-2022 APhA-APPM Executive Committee
Clinical Assistant Professor
University of Missouri—Kansas City School of Pharmacy
2021–2022 APhA–APPM Pharmacy Residency Standing Committee, Education and Training Subcommittee:

Edwin Shamtob, PharmD
Chair, 2021-2022 APhA-APPM Pharmacy Residency Education & Training Subcommittee
PGY-1 Community-based Pharmacy Resident
University of Southern California

Angela Li, PharmD
Co-Chair, 2021-2022 APhA-APPM Pharmacy Residency Education & Training Subcommittee
PGY-1 Community-based Pharmacy Resident
Albertsons Companies/Safeway/Regis University

Leanne Allas, PharmD
PGY-1 Community-Based Pharmacy Resident
Walgreens/University of Health Science and Pharmacy in St. Louis

Phyllisa Best, PharmD, MPH
PGY-1 Community-Based Pharmacy Resident
University of Arkansas for Medical Sciences/Walmart Health & Wellness

Ranelle Coffman, PharmD
PGY-2 Community-Based Pharmacy Resident
Kroger Health/University of Cincinnati

Regann Rutschilling, PharmD
PGY-1 Community-Based Pharmacy Resident
Family Health Services of Darke County

Paria Sanaty Zadeh, PharmD
Staff Liaison, APhA–APPM Pharmacy Residency Standing Committee
Associate Director, Practice and Science Programs
APhA
Washington, DC

Jessica Schrader, PharmD
PGY-1 Community-Based Pharmacy Resident
Rocking Horse Community Health Center

Bailey Scism, PharmD
PGY-2 Ambulatory Care Pharmacy Resident
AdventHealth Celebration

Sally Sun, PharmD
PGY-1 Community-Based Pharmacy Resident
University of California, San Francisco/Safeway

Last Updated 2/9/2023

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