CurrentHighmark Blueshield NenyPolicy RP-010

Incident-To Services

Defines Highmark BlueShield NE/NY reimbursement rules for billing services provided 'incident to' a physician or APP, including supervision, provider enumeration, and state-specific variations; applies to commercial and Medicare Advantage markets listed in the document.

Policy Summary

PayerHighmark Blueshield Neny

PolicyIncident-To Services

Policy CodePolicy RP-010

Change TypeNo material changes

Effective DateJan 1, 2021

Next Review Date

Key ActionSubmit claims with the supervising physician's information in both billing and rendering sections and append SA modifier when APPs render Incident-To services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PA, DE, WV, NYApplicable markets

100%Physician-billed payment

85%Common APP reimbursement

75%Behavioral health tier

SAModifier required (Commercial)

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When Incident-To Services Are Covered

inv-01: Incident-To coverage criteria

Covered when ALL of the following CMS and policy-specific conditions are met:

Service is an integral, incidental part of the supervising physician's professional service and medically necessary

Service is commonly furnished in physician offices/clinics and furnished by the physician or by auxiliary personnel under direct supervision

Physician (or eligible supervising professional) personally performed the initial service, established the diagnosis and plan of care for the specific medical problem

Physician or supervising APP remains actively involved in the course of treatment (subsequent physician services of a frequency that reflects continuing active participation and management)

Direct supervision is provided: the supervising physician/eligible professional is physically present in the office suite and immediately available to assist (virtual real-time audio/video presence is acceptable only for the duration of the PHE when reported with modifier FR)

An appropriate physician- or APP-approved plan of care is documented in the medical record; all new conditions/diagnoses require documented plan of care or supervising physician sign-off prior to Incident-To billing

Auxiliary personnel and APPs provide services only within their scope of license/certification and state law; services of unlicensed clinicians in training cannot be billed Incident-To

Services are furnished in Place of Service (POS) 11 (office) — Incident-To does not apply to hospital, skilled nursing facility, home, or other institutional settings except where supervising physician is physically present and direct supervision is met

inv-02: Incident To coverage criteria and billing rules

Conditions under which Incident-To services are covered and billing/payment implications:

Service must be integral to and incidental to the physician's professional service and part of an active plan of care where the physician or supervising APP performed the initial service and remains actively involved

Direct supervision is required (physician/eligible professional present in office suite and immediately available); general supervision applies only to behavioral health services per policy

Incident-To applies only to Place of Service (POS) 11; hospital, SNF, home and other institutional settings are excluded unless the supervising physician is physically present and direct supervision is met

When auxiliary personnel deliver Incident-To services, claims should be billed under the supervising provider's NPI; ancillary services billed under a physician NPI receive 100% of contracted fee schedule while ancillary services billed under an APP NPI are subject to standard APP payment reductions

inv-03: Incident To qualification criteria

Requirements to qualify services as 'Incident To' (does not apply to NY region):

Physician personally treats, establishes the diagnosis and develops the plan of care for the patient on the first visit for the specific medical problem; alternatively, the APP may render services if the supervising physician signs off on the new/updated plan of care

Physician remains actively involved in ongoing care; subsequent physician services must reflect continuing active participation and management (co-signature required on new care plans and new diagnoses)

A physician in the group (need not be the same physician) must be physically on-site when supporting personnel provide follow-up care on future visits

Both the supervising physician and supporting personnel must be employed or contracted by the billing group entity (W-2, leased employee, or independent contractor); sole practitioners must employ supporting personnel

Exclusions (do NOT qualify)

inv-04: APP payment reductions and enumeration

APP reimbursement reductions and independent billing requirements:

When services rendered by enumerated APPs do not meet Incident-To requirements and are billed under the APP's NPI, standard reimbursement reductions apply as specified by provider type and region

Examples of regional reductions

Behavioral health master-prepared therapists, LCSWs, LPCs, Marriage & Family Counselors — reimbursement = 75% of fee schedule (DE and PA regions)
Behavioral health NPs/CNS/psychiatric NPs — reimbursement = 85% of fee schedule (DE and PA regions)
Licensed Social Workers (commercial business only) — reimbursement = 65% of fee schedule (DE and PA regions)
Medical/surgical APPs (NP, CRNP, CNS, RNFA, Midwives, PAs where allowed) — reimbursement = 85% of fee schedule (DE, PA, and NY as specified)

inv-05: Incident To coverage criteria

Requirements for Incident-To billing

Physician must personally perform the initial service, establish the diagnosis and plan of care for the specific medical problem (or supervising physician must sign off on an APP-established plan)

Physician must remain actively involved in ongoing care; subsequent physician services should reflect active participation and management

A physician in the group must be physically on-site when supporting personnel provide follow-up care on future visits

Both the supervising physician and the supporting personnel must be employed or contracted by the billing group entity (W-2, leased employee, or independent contractor); sole practitioners must employ supporting personnel

Non‑qualifying situations

New patient visits (CPT 99202-99205) without supervising physician sign-off on plan of care do not qualify for Incident-To billing

inv-06: Incident To Coverage Criteria

Requirements for services to qualify as 'Incident To' billing:

Physician personally performs initial service, establishes diagnosis and plan of care for the problem on the first visit (new patient) or supervising physician signs off on the APP's plan of care

Physician remains actively involved in and manages the course of treatment; subsequent physician services must reflect continuing participation

Physician (or a physician in the group) must be physically on-site when supporting personnel provide follow-up care

Both supervising physician and supporting personnel must be employed or contracted by the billing group entity; sole practitioners must employ supporting personnel

Exclusions and billing instructions

New patient office visits (CPT 99202-99205) do not qualify for Incident-To billing

inv-07: Incident To qualification and reimbursement rules

Conditions required for services to qualify as 'Incident To' and reimbursement adjustments for APPs and auxiliary personnel.

Physician must personally perform the initial service, establish the diagnosis and plan of care for the new problem

Physician must remain actively involved in ongoing care with subsequent physician services reflecting continuing management

Direct supervision by a physician is required (physically present in the office suite) unless virtual direct supervision is allowed under the PHE with modifier FR

Exclusions

New patient office visits (CPT 99202-99205) do not qualify for Incident-To billing
Services for new conditions not addressed in an established plan of care — supervising physician must see patient and establish plan of care before Incident-To billing

Codes, Modifiers, and Payment Details

Psychological service codes (NY MA supplemental)CPTCovered

90785, 90832-90838, 90846-90849, 90853, 90880, 90899

Psychological/therapy HCPCS/CPT codes referenced for NY Medicare Advantage incident-to delegation

Behavioral health / psychological codes (NY MA)CPT

90785, 90832-90838, 90846-90853, 90880, 90899

Psychological/psychotherapy codes referenced for NY Medicare Advantage supplemental guidance

E/M new patient exclusionsCPTNot Covered

99202-99205

New patient office visit codes not qualifying for Incident To if no supervising physician sign-off

Excluded CodesCPTNot Covered

99202-99205

New patient office visit codes that do not qualify for 'Incident To' billing

Modifier requirementModifierCovered

SA	Modifier to indicate services rendered by APPs or other listed non-physician practitioners when billed 'Incident To'.

Payment differential

Physician-billed paymentAncillary services billed under a physician NPI receive 100% of the contracted fee schedule.

APP-billed paymentIncident-To ancillary services billed under the APP NPI are subject to standard APP reductions (reduced percentage of fee schedule).

Modifier noteFor Commercial business, the SA modifier must be appended to all Incident-To services when services are rendered by an APP.

APP reductions

Standard APP reductionsServices billed under an APP NPI will be subject to standard APP reimbursement reductions when Incident-To requirements are not met.

Physician NPI exceptionAncillary services billed under a physician NPI are paid at 100% of the contracted fee schedule and are not subject to APP reductions.

Enumeration requirementAPPs who independently diagnose new problems and establish plans of care must be enumerated in the payer system prior to using their rendering NPI to avoid claim rejection.

Behavioral health reimbursement rates

Masters-prepared therapists / LCSWs / LPC / MFTReimbursement = 75% of fee schedule (DE and PA regions).

NP / Clinical Nurse Specialist (psychiatric) / CRNP (psychiatric)Reimbursement = 85% of fee schedule for behavioral health services (DE and PA regions).

Licensed Social Workers (commercial only)Reimbursement = 65% of fee schedule (applies to Commercial business in listed regions).

Medical/surgical APP reimbursement rate

Medical/surgical APPs (NP, CRNP, CNS, RNFA, Midwives, PA)Reimbursement = 85% of fee schedule (DE, PA and NY regions where applicable).

Physician AssistantsReimbursement = 85% of fee schedule where allowed by law (DE, PA, NY as specified).

Scope noteReductions apply to codes where care delivery is determined by the practitioner's knowledge, skills, and abilities (e.g., E/M, procedures, psychotherapy); commodity services on same claim (vaccines, drugs, labs) are excluded from reductions.

Reimbursement reduction thresholds

Typical reduction levelsAPP services reimbursed at defined percentages when not billed Incident-To (examples: 85% for many medical/surgical APPs; behavioral health tiers: 75%, 85%, 65%).

Application to code typesReductions apply to practitioner-determined services (E/M, procedures, psychotherapy); commodity services submitted on same claim are not reduced.

Region-specific applicabilityBehavioral health reductions apply to DE and PA regions only; medical/surgical reductions apply to DE, PA and NY (where specified).

Reimbursement reductions examples

Behavioral health example ratesMaster-level therapists/LCSWs/LPCs/MFTs = 75%; NP/CRNP psychiatric providers = 85%; Licensed Social Workers (commercial) = 65%.

Medical/surgical example ratesNP/CRNP/CNS/RNFA/Midwives/PA = 85% of fee schedule for applicable services.

Exclusion exampleCommodity services (vaccines, drugs, labs, diagnostics) on the same claim are not subject to the reductions.

New patient visit CPT range excluded from Incident To

Excluded CPT rangeNew patient office visit codes CPT 99202-99205 must not be billed as 'Incident To' (no sign-off on plan of care).

New condition requirementNew conditions/diagnoses encountered require physician sign-off on a plan of care before Incident-To billing may be used.

Place of service constraintIncident-To billing applies to office setting (Place of Service 11) and does not apply in institutional settings unless physician is physically present and direct supervision criteria are met.

Claim Submission, Enumeration, and Supervision Requirements

Billing Rule

Rendering or Performing Provider Enumeration

Advanced Practice Providers (APPs) defined as any of the following must list themselves as the rendering/performing provider on the CMS-1500 claim when they deliver the service (and are different than the billing provider): Physician Assistant; Clinical Nurse Specialist; Nurse Practitioner; All master's-prepared behavioral health therapists (including LCSW and LSW); Licensed Professional Counselors; Licensed and Associate Marriage and Family Counselors; Certified Registered Nurse Practitioner (CRNP); Certified Registered Nurse; Therapists and Counselors; Pharmacist* (Applicable only to Medicare Advantage and West Virginia commercial plans). Note: This requirement does not apply to the New York region — all NY APPs must list as rendering providers. Note: "Incident To" services only apply to place of service (POS) 11.

Failure to enumerate and list the rendering provider when different than the billing provider may result in post-payment investigation and recoupment or claim rejection.
If the rendering provider is not enumerated in Highmark systems the claim can be rejected; the claim may be resubmitted once the rendering provider is credentialed and enumerated in the Plan's system.

Billing Rule

APP Billing Procedure / Billing NPI and Modifier Requirements

Ancillary staff billing "Incident To" services should populate the rendering provider field with the ordering physician or APP NPI if different than the billing provider NPI. For commercial business, the SA modifier must be appended to all "Incident To" services when services are rendered by an APP and billed as "Incident To" the supervising physician. Incident-To ancillary services billed under an APP NPI will be subject to the plan's standard APP reimbursement reductions; ancillary services billed under a physician NPI will receive 100% of the contracted fee schedule.

Use supervising physician or APP NPI in rendering provider field when billing Incident-To.
Append SA modifier to each CPT/HCPCS line when APPs bill "Incident To" the supervising physician (commercial business).
Incident-To billing can only be claimed if the supervising physician established the initial plan of care for the specific NEW problem and the supervising physician is available per supervision rules.

Billing Rule

Rendering provider enumeration and modifier

All applicable APPs who independently bill Highmark must be separately enumerated in Highmark's provider systems and must list themselves as the rendering provider on the CMS-1500 when they performed the service. Failure to enumerate prior to billing may result in claim rejection.

Rendering providers who practice independently (see policy definition: see new patient / independent plan of care) must enumerate with Highmark before billing.
If an APP performs the service, they must be listed in the rendering provider field; otherwise the claim may be denied or recouped.

Note

State-specific limitation (DE)

Delaware commercial primary care reimbursement: Effective January 1, 2024, due to 18 Del. Admin. Code § 1322-5.0, this policy's provisions only apply to commercial market reimbursement for services rendered by contracted primary care providers in Delaware. The policy does not apply to non-primary care commercial services in Delaware.

Applies to contracted primary care providers in Delaware only (commercial market) as of 2024-01-01.
Inapplicable for non-primary care commercial services in Delaware.

Note

Direct supervision virtual allowance (PHE)

Direct supervision requires the supervising physician to be immediately physically available to assist without delay (for example, in the office suite) and supervision must comply with state licensure/certification requirements. For purposes of the Public Health Emergency (PHE), the plan follows CMS guidance allowing direct supervision to include virtual presence (real-time interactive audio/video) for the duration of the PHE; when virtual direct supervision is used, report applicable services with modifier FR when appropriate.

Direct supervision standard: supervising physician immediately physically available to assist without delay to qualify for "Incident To" billing.
PHE exception: virtual direct supervision allowed (real-time audio/video) per CMS guidance — report modifier FR when applicable.
Certain diagnostic tests with extended technical components (e.g., Holter monitoring, cardiac event monitoring, sleep studies) may be performed without physician present; technical components may be performed by appropriately licensed/certified technicians and payment can be made to the supervising provider if criteria met.

Billing Rule

Incident To claim submission and modifier/enumeration requirements

Providers billing "Incident To" should submit each claim with the supervising physician's information in both the billing and rendering sections when billing under the supervising physician. Each CPT/HCPCS line billed "Incident To" must include the SA modifier to indicate that someone other than the supervising physician delivered the service. The supervising physician is responsible for delivery of supervised services. Ancillary staff billing Incident-To should use the ordering physician or APP NPI in the rendering provider field if different than the billing provider NPI.

Submit claims with supervising physician information in both billing and rendering fields when billing "Incident To" under the physician.
Each line CPT/HCPCS billed "Incident To" must have SA modifier when APPs bill "Incident To" the supervising physician.
Ancillary services billed under APP NPI are subject to APP reimbursement reductions; ancillary services billed under physician NPI receive 100% of contracted fee schedule.

Prior Authorization

Claim Submission and Enumeration — provider actions to avoid denials

Key provider actions to avoid claim denials or recoupment: ensure APPs are enumerated in Highmark systems before billing; list the correct rendering provider NPI on the CMS-1500; append SA modifier to each line when APPs bill "Incident To" the supervising physician (commercial business); when using virtual direct supervision during the PHE, follow CMS guidance and report modifier FR where applicable. Maintain documented physician-approved plan of care for any "Incident To" services (required for new conditions/diagnoses).

Ensure APP enumeration in Highmark prior to billing to avoid rejection.
Report supervising physician NPI in billing and rendering sections when billing "Incident To" under physician.
Append SA modifier to each CPT/HCPCS line for Incident-To services rendered by APPs.
Document and maintain physician-approved plan of care before billing Incident-To for new conditions.

Key Terms and Supervisory Definitions

APP

DefinitionAPP = Advanced Practice Provider; includes NP, PA, CNS, CNM and other listed roles.

ExamplesCommon APP categories referenced: Nurse Practitioner (NP), Physician Assistant (PA), Clinical Nurse Specialist (CNS), Certified Nurse Midwife (CNM), RNFA.

Enumeration noteAPPs must enumerate/list themselves as the rendering provider on the CMS 1500 when independently diagnosing and establishing a plan of care to avoid claim rejection.

Direct supervision

Core definitionDirect supervision requires the supervising physician or eligible professional to be immediately physically available to assist without delay (e.g., present in the office suite).

PHE exceptionFor the duration of the Public Health Emergency (PHE), CMS proposed rules allow direct supervision to include virtual presence via real-time audio/video; report applicable services with modifier FR when appropriate.

State/licensure complianceAll supervision must comply with state licensure or certification requirements of the performing practitioner.

General supervision

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

Behavioral health noteGeneral supervision only applies to behavioral health services per policy.

ApplicabilityGeneral supervision does not meet Incident-To direct supervision requirements for most services; check section-specific rules.

Selected terms

SA modifierSA = modifier indicating services rendered by an APP in collaboration with a physician; must be appended to Incident-To services for Commercial business when rendered by an APP.

FR modifierFR = modifier indicating the supervising practitioner was present via two-way audio/video communication technology (used for virtual direct supervision during PHE).

Enumerated definitionEnumerated = assignment of a specific identifying number to a provider for submission on claims; APPs who bill independently must be enumerated to avoid claim rejection.

Supervision

Supervision umbrellaSupervision includes direct and general supervision definitions; direct supervision requires immediate physical availability, while general supervision is overall direction and control without required presence.

Behavioral health exceptionNote that general supervision is specifically applicable to behavioral health services under this policy.

State complianceAll supervision must comply with state licensure or certification requirements of the performing practitioner.

'Incident To' definition (short)

Short definition'Incident To' services are those furnished by someone other than the supervising physician and billed under the physician's NPI when the physician established the initial plan of care and remains actively involved.

Payment when compliantWhen Incident-To requirements are met, services are paid at 100% of the contracted fee schedule.

ScopeAlso applies to auxiliary personnel working within their scope of license when supervised appropriately by physicians or certain APPs.

Direct supervision (PHE virtual allowance)

PHE virtual allowanceDuring the Public Health Emergency, direct supervision may include virtual presence of the supervising physician using real-time interactive audio and video technology; report with modifier FR when appropriate.

Standard requirementOutside the PHE exception, direct supervision requires the supervising physician to be immediately physically available in the office suite to assist without delay.

ReportingWhen virtual direct supervision is used per PHE guidance, services should be reported with modifier FR as appropriate.

Incident To services (detailed)

Incident-To service criteriaServices must be part of the patient’s normal course of treatment, with the physician personally performing the initial service and establishing the diagnosis and plan of care (or signing off on an APP-established plan).

Employment/contractingBoth supervising physician and supporting personnel must be employed or contracted by the billing group entity (W-2, leased employee, or independent contractor); sole practitioners must employ supporting personnel.

Claim submissionWhen billing Incident-To, submit claims with the supervising physician's information in billing and rendering fields and append SA modifier when APPs deliver services (Commercial business).

Direct supervision (alternate chunk)

Alternate direct supervision wordingDirect supervision means the supervising physician must be immediately physically available to assist without delay (e.g., in the office suite).

PHE exception restatedFor the duration of the PHE the Plan will follow CMS proposed rule to allow virtual presence via real-time interactive audio/video as direct supervision (report with modifier FR).

State/licensure requirementAll supervision must align with state licensure or certification requirements of the performing practitioner.

Employment relationship

Employment relationship definitionAn employment relationship is established when employer has power to hire/fire, directs work and performance, pays wages/benefits, and no facility compensation is received for the employee during employment.

Implication for Incident-ToBoth supervising physician and supporting personnel must have an appropriate employment/contract relationship with the billing entity for Incident-To billing eligibility.

Documentation requirementEmployment relationship criteria must be sufficiently documented to support Incident-To billing and applicable reimbursement rules.

'Incident To' services definition (alt)

Alternate short definition'Incident To' services are those furnished by someone other than the supervising physician and billed under the physician's NPI, provided they meet supervision and plan-of-care requirements.

ApplicabilityApplies when physician performed initial service and remains actively involved in ongoing care; otherwise APP must bill under own NPI.

Payment effectWhen requirements met, services receive 100% of contracted fee schedule.

Direct supervision (alt)

Direct supervision restatementDirect supervision requires an eligible professional be immediately physically available to assist without delay (in the office suite) to qualify for Incident-To billing.

General supervision distinctionGeneral supervision (physician not present) is distinct and generally does not satisfy Incident-To direct supervision requirements except for behavioral health where general supervision may apply.

PHE reportingDuring the PHE, virtual presence using real-time audio/video may meet direct supervision if reported with modifier FR when appropriate.

'Incident To' services description

Incident-To core definition'Incident To' services are furnished by someone other than the supervising physician and billed under the physician's NPI when the physician established initial plan of care and remains actively involved.

Office setting requirementThese services are typically furnished in physician offices/clinics and must meet supervision and plan-of-care documentation requirements.

Payment when compliantWhen requirements are met, 'Incident To' services are paid at 100% of contracted fee schedule.

Supervision physical availability requirement and PHE exception

Physical availability requirementSupervising provider must be immediately physically available in the office suite to assist without delay for direct supervision.

PHE exceptionDuring the COVID-19 PHE the Plan follows CMS guidance allowing virtual presence (real-time audio/video) to satisfy direct supervision where appropriate and reported with modifier FR.

Scope and complianceAll supervision actions must be in accordance with applicable state licensure/certification requirements of the performing practitioner.