Medicare ADVISOR Q&A

Billing Medicare 'Incident To': Some Questions

Question: I am a physical therapist working in a physician owned outpatient orthopedic setting and we bill PT services "incident to" the physician (even though I have a Medicare provider number). I have several questions re: Medicare patients:

(1) The physicians sometimes send us same day "walkovers" for initial therapy sessions, can we bill for PT services the same day that a physician evaluates/treats a patient? Sometimes these patients are for home exercise programs only, do we have to bill for an initial evaluation or can we bill for one therapeutic exercise?

(2) We sometimes get referrals for PT from MD's outside of our practice, do our physicians need to see these patients (Medicare and private insurance) first before we bill them "incident to" our physicians or do we need to bill them through me? Can you cite specific references in the Medicare Benefit Policy Manual?


Answer: First of all you need to decide "which hat am I wearing" as you are working under two different "sites of service" regulations.

Incident to services are services that directly relate to the physician's practice and are billed as if it were the physician doing the service. The "incident to therapy" was allowed because most of the other incident -to services are performed in the office, that day, example X-ray, blood work etc. Therefore seeing the patient the same day as they see the MD is appropriate to that site of service. Under these regulations, the physician should do the evaluation and write the plan of treatment. Providing instruction and training on a Home Exercise Program can be performed and the services billed under therex for the time that it took.

The next question is where you are "switching hats". Under the incident-to rule, Medicare is being billed for the physicians' patients, not those of others unless they are referred to and then seen by the physician. If this is the case, then once again you are billing as if the physician is treating the patient.

When you bill under your number, then you are acting as a PT in Private Practice and you are responsible for doing the evaluation and creating a plan of treatment. In this case you would bill the evaluation and then whatever treatment you provided that day.


Question:. In treating concurrently do the 2 patient which you are treating have to be doing 2 different exercises, i.e. ther-ex and neuro, or is it ok for both of them to be doing ther-ex?


Answer: The answer depends and how you are billing. If you are billing under Part B and seeing 2 patients concurrently, then Medicare does not have any regulation on what they are doing but they must be billed each 1 unit of group therapy CPT 97150. So you can be providing same, similar or totally different services.

If you are billing under Part A SNF, then concurrent is defines as 2 patient not doing safe or similar activities. This does not mean that one must be doing neuro and the other ther-ex, it means that one could be doing UE activities and the other balance or pre-gait. Presently, under Part A, group is defined as 2 to 4 people who are doing the same or similar activities, so here the patients could be working on the same type of activities with a specific goal in mind, for example, both doing LE exercises to increase strength and coordination, but they would not necessarily be doing the same exact exercises in unison.


Disclaimer: The answers provide are based on Medicare guidelines for what is payable under the Medicare Part A and Part B Benefit. As always, the provider should be aware of the other regulations that might supersede the Medicare payment guidelines such as the State Practice Act and the State Administrative Code. In any scenario, the practitioner must go with the most stringent requirement in order to be compliant. The information provided is current as of the time of publication.


Pauline M. Franko, PT is owner of Encompass Consulting & Education, LLC; a consulting and education company specializing in Medicare Consulting, Compliance Training and Medicare Seminars, based in Tamarac, FL. Visit Encompass's website at to learn more about the services they provide. The company's "Direction on Demand" service specializes in providing the rehabilitation professional with a clear, easy way to understand how to provide Medicare compliant services to their patients in the SNF and Outpatient settings. You may contact the author through the Encompass website or by phone at 954-720-4087.


Medicare Advisor Archives

Our Occupational Therapy dept. is owned by the physicians in our Orthpaedic office. We bill as incident-to, however we are having issues with claims coming back denied stating that the provider is practicing outside of their practice. Do we bill under the therapist to prevent this?

Tabitha  LanceDecember 02, 2016
Spartanburg, SC

can we bill for accepted WC cases for pain management visit and PT on the same day? The PT and office visit are done in the same location. The pain management visit is with an MD or DO doctor and the PT is done by a license therapist under the PM&R doctor. I have heard that you cannot see the patient and then refer the patient for PT at the same location, please help.

Nikki Trejo,  Billing Collection CoordinatorSeptember 28, 2016
Santa Ana, CA

Billing 'Incident to therapy'. Our orthopaedic clinic has its own physical therapy department. We are having difficulty with secondary claim submission with our new billing software. Some claims file under the therapist for primary, yet the system stops the claims before secondary submission stating the therapist is 'not a billable provider' for certain secondary carriers. (All providers ARE set up correctly in our system per their individual credentials and carrier contracts.) We are being told by someone outside our clinic that it is appropriate to alter the claim form between primary and secondary carriers to get the claims out of the system, changing the rendering provider from therapist to the physician, since the therapist is incident to the physician, yet we hesitate to alter the claim form in any way. Is this legal by Medicare standards? Can you site a resource if it is not legal?

gretchen February 10, 2013

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