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Chapter 4.5. Division of Workers' Compensation
SUBCHAPTER 1. ADMINISTRATIVE DIRECTOR -ADMINISTRATIVE RULES
Article 5.3. Official Medical Fee Schedule
§9789.15.2. Non-Physician Practitioner (NPP) - “Incident To” Services.
(a) Non-institutional Setting.
For purposes of this section a non-institutional setting means all settings other than a hospital or skilled nursing facility.
(1) Services that are furnished incident to a physician's are commonly included in the physician's bills, and for which no separate payment is made. Diagnostic tests and pneumococcal, influenza, and hepatitis B vaccines need not also meet the incident to requirement in this section.
(2) NPPs may provide services without direct physician supervision and bill directly for these services. When their services are provided under direct physician supervision, their services may be covered as incident to services, in which case the incident to requirements would apply.
(3) To be covered incident to the services of a physician, services must be:
(A) An integral, although incidental, part of the physician's professional service;
(B) Commonly rendered without charge or included in the physician's bill;
(C) Of a type that are commonly furnished in physician's offices or clinics;
(D) Furnished by the physician or by auxiliary personnel under the physician's direct supervision.
(b) Institutional Setting.
Hospital services incident to physician's services rendered to outpatients and partial hospitalization services incident to such services are subject to the incident to requirements. Payment for these services is made to a hospital.
(c) Incident To Physician's Professional Services
Incident to a physician's professional services means that the services are furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness. See section 9789.19 for “incident to” codes by date of service.
(1) Services Commonly Furnished in Physicians' Offices.
Services commonly furnished in physicians' offices are covered under the incident to provision. Charges for such services must be included in the physicians' bills. Where services are of a type not considered medically appropriate to provide in the office setting, they would not be covered under the incident to provision.
(2) Direct Personal Supervision.
(A) Services incident to the professional services of a physician in private practice is limited to situations in which there is direct physician supervision of auxiliary/NPP personnel. The incident to services must represent an expense incurred by the physician or legal entity billing for the services.
(B) Where a physician supervises auxiliary/NPP personnel to assist him/her in rendering services to patients and includes the charges for their services in his/her own bills, the services of such personnel are considered incident to the physician's service if there is a physician's service rendered to which the services of such personnel are an incidental part and there is direct supervision by the physician.
(C) To be considered incident to, each occasion of service by auxiliary/NPP personnel needs also to always be the occasion of the actual rendition of a personal professional service by the physician. Such a service could be considered to be incident to when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment. However, the direct supervision requirement must still be met with respect to every non-physician service.
(D) Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.
(E) If auxiliary/NPP personnel perform services outside the office setting, e.g., in a patient's home or in an institution (other than hospital or skilled nursing facility (SNF)), their services are covered incident to a physician's service only if there is direct supervision by the physician. For example, if a nurse accompanied the physician on house calls and administered an injection, the nurse's services are covered. If the same nurse made the calls alone and administered the injection, the services are not covered (even when billed by the physician) since the physician is not providing direct supervision.
(F) The availability of the physician by telephone and the presence of the physician somewhere in the institution does not constitute direct supervision for services provided by auxiliary/NPP personnel in an institution (e.g., nursing, or convalescent home).
(G) There is no payment for services of physician-employed auxiliary/NPP personnel as services incident to physician service.
(H) A NPP who performs a specific medical procedure without physician supervision may receive separate payment for the service as a NPP's service.
(d) Incident to physician's services in clinic.
Services incident to a physician's service in a physician directed clinic or group association are generally the same as those described in this subsection.
A physician directed clinic is one where:
(1) A physician (or a number of physicians) is present to perform medical (rather than administrative) services at all times the clinic is open;
(2) Each patient is under the care of a clinic physician; and
(3) The non-physician services are under medical supervision.
(4) In highly organized clinics, particularly those that are departmentalized, direct physician supervision may be the responsibility of several physicians as opposed to an individual attending physician. In this situation, medical management of all services provided in the clinic is assured. The physician ordering a particular service need not be the physician who is supervising the service.
(5) When the auxiliary/NPP personnel perform services outside the clinic premises, the services are covered only if performed under the direct supervision of a clinic physician. If the clinic refers a patient for auxiliary/NPP services performed by personnel who are not supervised by clinic physicians, such services are not incident to a physician's service.
Note: Authority: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 5307.1 and 5307.11, Labor Code.
1. New section filed 9-24-2013; operative 1-1-2014. Submitted to OAL as a file and print only pursuant to Government Code section 11340.9(g) (Register 2013, No. 39).
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