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BLUECONNECT
Providers
January 2024
In This Issue
► January news: Executive summary
► 2024 Medicare Advantage networks and plans
► "Incident-to" billing: What you need to know
► Updated pricing guidelines for E/M services provided in emergency departments
► Cervical cancer screening: Provider guidance for 2024
"Incident-to" billing: What you need to know
The Blue Cross® Blue Shield® of Arizona (AZ Blue) Special Investigations Unit routinely reviews medical records and investigates possible issues. One thing they often notice is confusion about “incident-to” billing. 
Eligibility for incident-to billing
We allow incident-to billing for the following provider types who render services within the scope of their specialty training and licensing, and bill under the supervising provider’s name and NPI number:
• Non-physician providers with a credential that is ineligible for an independent contract with AZ Blue (including, but not limited to, clinical nurse specialists, physical or occupational therapy technicians, registered behavior technicians, licensed associate counselors, licensed associate marriage and family therapists, licensed associate substance abuse counselors, and licensed master social workers)
• Non-physician providers who are eligible for an independent contract with AZ Blue but are employed by a physician or practice and are not practicing independently of the employment relationship
Example of “incident to” service 
An example of a qualifying “incident to” service is when a physical therapist creates a treatment plan of covered services for a patient and assigns a physical therapy technician to carry out the plan or parts of it under the direct supervision of the physical therapist. The technician’s services can be billed “incident to” using the therapist’s name and NPI as the rendering provider.
Requirements for incident-to billing
We allow “incident to” billing only if the following conditions are met:
1. The covered services must be part of the patient’s normal course of treatment, during which the supervising provider personally performed an initial service (for that condition) and remains actively involved in the management of the course of treatment. 
Exception: Certain licensing boards allow a supervised practitioner to perform the initial service and create the treatment plan when overseen by the supervising provider (e.g., associate counselor).
2. The covered services or supplies must be furnished as an integral part of the supervising provider’s professional services in the course of diagnosis or treatment of an injury or illness.
3. The supervised practitioner must represent a direct financial expense to the supervising provider or the provider’s group (such as a “W-2” or leased employee, or an independent contractor).
4. The supervising provider must directly oversee the subordinate practitioner and ensure that that person is acting within the scope of his or her training/certification, as applicable.
5. The supervising provider does not have to be physically present in the patient’s treatment room while the services are provided but must be readily available to provide assistance and direction throughout the time the services are administered. For example, if the patient mentions a new medical issue during the course of treatment, the supervising provider must come into the treatment room and evaluate the patient for the new issue.
6. The patient record clearly documents satisfaction of all stipulations listed in requirements 1 and 2 above regarding the patient’s care. This means the record identifies the supervising physician and indicates the availability of the supervising physician, as required.
For homebound patients in areas where there are limited healthcare providers, supervision may be more general for certain medical services (see CMS Pub 100-02, Chapter 15, section 60.4 B). However, the supervising provider must order the services, maintain contact with the nurse or other employee, and retain professional responsibility for the services. All other “incident to” requirements must be met.

Another exception applies when the covered service provided at a patient’s home is a one-time or intermittent service performed by personnel meeting pertinent state requirements (e.g., a nurse, technician, behavioral health paraprofessional, or physician extender) and is an integral part of the physician’s services to the patient.
More information
For more information about AZ Blue requirements for incident-to billing, check out this excerpt from the 2024 Provider Operating Guide. Keep in mind that other states and other health plans may have additional or different requirements for incident-to billing. If you have questions, please contact your Provider Relations Contact. 
In This Issue
► January news: Executive summary
► 2024 Medicare Advantage networks and plans
► “Incident-to” billing: What you need to know
► Updated pricing guidelines for E/M services provided in emergency departments
► Cervical cancer screening: Provider guidance for 2024
© 2024 Blue Cross Blue Shield of Arizona, Inc. All rights reserved.

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