Following incident-to billing rules is essential for any medical practice leveraging nonphysician providers such as nurse practitioners, physician assistants, clinical nurse specialists, or certified nurse midwives. One reason this is important is because incident-to billing rules discourage scope creep — something the American Medical Association says threatens patient safety and undermines physician-led, team-based care.
In this guide, medical practices can learn how to follow incident-to billing rules and how to prevent scope creep.
What is scope creep?
Scope creep occurs when clinicians or staff perform tasks outside their defined scope of practice as set by state licensing laws, professional board regulations, and facility or payer policies. Incident-to billing rules help safeguard against scope creep because they:
- Maintain clear role differentiation
- Reinforce documentation and accountability
- Require direct supervision
- Restrict billing to established patients and problems
- Tie each service to a physician-established plan of care
Why to follow incident-to billing rules
Following incident-to billing rules also promotes revenue integrity and optimization. When services meet incident-to requirements, practices can bill those services under the supervising physician national provider identifier (NPI) and receive 100% of the Medicare physician fee schedule (MPFS) rate. If billed under the nonphysician provider’s own NPI, payment drops to 85% of the MPFS.
In addition to promoting revenue integrity and preventing scope creep, adherence to incident to billing rules also increases compliance and audit protection. This includes protection against:
- Overpayment demands
- Civil monetary penalties
- Allegations of false claims
The Office of Inspector General (OIG), for example, is currently reviewing Medicare Part B payments for incident-to services and expects to issue a full report in fiscal year 2026. It will be important to read the report once it becomes available and continue following incident to billing rules to ensure documentation and supervision meet the Centers for Medicare and Medicaid Services’ (CMS) strict standards.
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Avoiding financial penalties
When leveraged appropriately, nonphysician providers can boost operational efficiency by supporting team-based care, continuity for established patients, and better patient access and physician time management. However, this is only true when medical practices avoid scope creep and follow incident to billing rules correctly.
Unfortunately, there are many examples of practices that didn’t follow incident to billing rules and paid the price. Consider the New York-based medical practice that agreed to pay $455,000 for failing to satisfy incident-to billing requirements for billing services provided by nurse practitioners who were not employed by, or under contract with, the medical practice.
Or the medical group that agreed to pay $33,000 for failing to satisfy incident-to requirements when it submitted claims for incident-to services performed by a nurse practitioner when the physician was not present in the office suite to provide direct supervision. A urology practice recently paid $463,000 for that same reason. And the same is true for a dermatology practice that paid $20,000.
Promoting compliance and revenue integrity
It may seem risky to provide incident-to services, but with the right guardrails in place, medical practices can avoid scope creep as well as legal and financial risk. Here are five steps that can enhance compliance.
- Audit clinical documentation. Consider auditing at least 10% of nonphysician provider claims to determine whether they comply with all Medicare requirements for incident-to services. For example, does clinical documentation include the initiating physician’s plan of care? What about the supervising physician’s name and presence on the date when services are provided, as well as details about how the physician remains actively involved in the patient’s care? Here’s a tool that can help you get started.
- Create internal incident-to policies. Align standards with Medicare requirements and incident to billing rules. Policies should also address what the practice will do when the supervising physician is absent. A supervision absence protocol should include a backup supervising physician list and billing guidance by service type.
- Educate providers and staff. Train everyone on supervision and documentation requirements for incident-to services versus shared/split billing.
- Leverage clear supervision logs. Ensure there is documentation that supervising physicians are present in the office suite when nonphysician providers see patients.
- Seek legal or compliance expertise. Consider consulting with healthcare compliance experts or healthcare attorneys to verify your billing practices.
Additional incident-to resources
Looking for additional resources to boost incident to billing compliance? Be sure to check out the following:
- CMS Internet Only Manual, Chapter 12 and Chapter 15
- Interactive incident-to billing tool, available at https://www.novitas-solutions.com/webcenter/portal/MedicareJH/IncidentTool
- Medlearn Matters article SE0441, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf
- Novitas Solutions incident-to provider education, available at https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00150920
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- Current Version – Dec 05, 2025Written by: Jean LeeChanges: This article was updated to include the most relevant and up-to-date information available.
- Nov 28, 2025Written by: Jean LeeChanges: Updated to reflect the most recent information available.
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