CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Professional Reporting Requirements for Services Not Personally Performed (AKA "Incident to Services")

Defines BCBSRI's reimbursement and reporting rules for professional services performed by persons other than the reporting provider in office settings; applies to professional providers and participating clinicians across all product lines.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyProfessional Reporting Requirements for Services Not Personally Performed (AKA "Incident to Services")

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateMar 15, 2011

Next Review DateFeb 19, 2025

Key ActionContact the provider call center for member-specific benefits and coverage determinations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All product linesPolicy applies to

99211 onlyE/M allowed

GC, GETeaching physician modifiers

1Related policy referenced

Reporting and Supervision Requirements

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Reporting and supervision criteria

Coverage stance and criteria for services not personally performed by the reporting provider.

BCBSRI does not cover services or make payment using 'incident to' for services provided by eligible providers.

BCBSRI has sole authority to determine whether a person who performs a service in a physician's office is qualified so that a physician may report the service, and to determine what services may be personally performed by other than the reporting provider.

All persons must practice within the scope of licensure and comply with applicable laws and regulations; all services must be covered, medically necessary, and correctly coded.

All services must be ordered by the reporting professional and be part of the established treatment plan of the reporting professional, with documentation present in the medical record or provider policy/procedure documents as applicable.

Supervision by the reporting provider is required for any service not personally performed by the reporting provider; BCBSRI determines required supervision level.

When supervision is sufficient to allow reporting by the professional for services not personally performed, Medicare levels of supervision apply as indicated on the applicable Medicare Physician Fee Schedule unless otherwise noted.

Evaluation and Management (E/M) services: only CPT 99211 may be reported when personally performed by other than the reporting professional; direct supervision is required. Prescription refills without face-to-face E/M by the reporting professional are not separately reportable.

Medication and immunization administration (including inhalation treatments and allergen immunotherapy injections): direct supervision is required and administrations must be part of the physician or qualified mid-level practitioner plan of care for the provider to report these services when not personally performed.

Psychiatric therapeutic procedures must be personally performed. In teaching settings personal supervision is allowed and may be accommodated by observation (one-way glass or video); retrospective review is insufficient to report the service unless BCBSRI has explicitly approved special reporting arrangements in writing.

Surgery: the reporting provider shall perform the service or shall supervise qualified postgraduate trainees in a teaching program setting consistent with Medicare Teaching Physician Guidelines.

Therapy services (Physical, Occupational, Speech): eligible providers must report their services. PTAs and OTAs may perform services reported by the supervising PT/OT under direct supervision and an established care plan; physicians and mid-level practitioners may not supervise OTAs/PTAs; services by students or auxiliary personnel may not be reported. Speech-Language Pathology services must be personally performed.

Miscellaneous services that may be performed by others (examples): accessing/flushing/cleaning VAD/PICC, replacement cast application, insertion of non-indwelling bladder catheter, technician-administered psychological testing, kidney disease education (see separate policy), phototherapy, and refilling/maintenance of implantable drug pumps.

Coverage of each specific service is defined in the member certificates/agreements and BCBSRI retains final authority for coverage determinations.

Codes, Modifiers, and Supervision Levels

Covered CPT CodesCPTCovered

99211

Only 99211 may be reported when personally performed by other than the reporting professional; direct supervision required.

Covered HCPCS ModifiersHCPCSCovered

GC	Service performed in part by resident under direction of teaching physician.
GE	Service performed by a resident without presence of teaching physician under primary care exception.

Notable Codes/Modifiers (mixed)mixedCovered

99211	Only 99211 may be reported when personally performed by other than the reporting professional; direct supervision required.
GC	Service performed in part by resident under direction of teaching physician.
GE	Service performed by a resident without presence of teaching physician under primary care exception.

Levels of supervision defined

General SupervisionProcedure furnished under physician's overall direction and control; physician presence not required during performance; physician remains responsible for training of non-physician personnel and maintenance of equipment and supplies.

Direct SupervisionPhysician must be present in the office suite and immediately available to furnish assistance and direction throughout the procedure; physician need not be in the room.

Personal SupervisionPhysician must be in attendance in the room during the performance of the procedure.

Prior Authorization and Benefit Verification

Note

Prior Authorization

Prior authorization is not required for services described in this policy.

Note

Benefit Verification / Member-Specific Inquiries

For benefit verification or member-specific coverage determinations, contact the Blue Cross Blue Shield of Rhode Island provider call center. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement and those documents supersede this medical policy.

Contact the provider call center for member-specific benefits and coverage determinations
Do not rely solely on this medical policy for eligibility or coverage — verify with the member's benefit documents

Policy Purpose, Supervision Definitions, and Billing Responsibility

General Supervision

DefinitionGeneral supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during performance.

Physician responsibilitiesUnder general supervision the physician is responsible for training the non-physician personnel who perform the diagnostic procedure and for maintenance of necessary equipment and supplies.

Use contextApplies when services are performed by non-physician personnel under the physician's overall direction in office settings.

Direct Supervision

DefinitionDirect supervision in the office setting requires the physician to be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure.

Presence requirementPhysician does not have to be present in the room when the procedure is performed.

ApplicabilityRequired for certain services (e.g., administration of medications, immunizations) when reported by the supervising provider for services not personally performed.

Personal Supervision

DefinitionPersonal supervision means a physician must be in attendance in the room during the performance of the procedure.

ImplicationUsed when the reporting physician must personally observe or participate in the service being performed.

ContrastStricter than direct supervision which allows physician to be in the office suite but not necessarily in the room.

Policy purpose and limits

Policy intentThis medical policy is made available for informational purposes only and is not a guarantee of payment or a substitute for clinical judgment.

Governing documentsBenefits and eligibility are determined by the member's subscriber agreement/member certificate and/or employer agreement, which supersede this policy.

Member-specific inquiriesFor information on member-specific benefits, providers should call the provider call center.

Provider billing responsibility

Charging members for non-covered servicesProviders may not charge a member for services determined to not be medically necessary (or for some medically necessary services that are non-covered) unless the member has been informed and has agreed in writing in advance to continue treatment at their own expense.

Reference to participation agreementsProviders should refer to their participation agreement(s) for applicable provisions regarding member billing.

Benefit determinationsCoverage determinations and payment are subject to the member's subscriber or employer agreements and not solely the policy statement.