CMS Pub. 100-02, ch. 15, § 60

Service

(Rev. 12425; Issued: 12-21-23: Effective: 01-01-24; Implementation: 01-02-24)

B3-2050

A - Noninstitutional Setting

For purposes of this section a noninstitutional setting means all settings other than a hospital or skilled

nursing facility

Medicare pays for services and supplies (including drug and biologicals which are not usually self-administered) that are furnished incident to a physician’s or other practitioner’s services, are commonly

included in the physician’s or practitioner’s bills, and for which payment is not made under a separate

benefit category listed in §1861(s) of the Act. A/B MACs (A) and (B) must not apply incident to

requirements to services having their own benefit category. Rather, these services should meet the

requirements of their own benefit category. For example, diagnostic tests are covered under §1861(s)(3)

of the Act and are subject to their own coverage requirements. Depending on the particular tests, the

supervision requirement for diagnostic tests or other services may be more or less stringent than

supervision requirements for services and supplies furnished incident to physician’s or other

practitioner’s services. Diagnostic tests need not also meet the incident to requirement in this section.

Likewise, pneumococcal, influenza, and hepatitis B vaccines are covered under §1861(s)(10) of the Act

and need not also meet incident to requirements. (Physician assistants, nurse practitioners, clinical nurse

specialists, certified nurse midwives, clinical psychologists, clinical social workers, physical therapists

and occupational therapists all have their own benefit categories and may provide services without direct

physician supervision and bill directly for these services. When their services are provided as auxiliary

personnel (see under direct physician supervision, they may be covered as incident to services, in which

case the incident to requirements would apply.

For purposes of this section, physician means physician or other practitioner (physician, physician

assistant, nurse practitioner, clinical nurse specialist, nurse midwife, and clinical psychologist)

authorized by the Act to receive payment for services incident to his or her own services.

To be covered incident to the services of a physician or other practitioner, services and supplies must be:

• An integral, although incidental, part of the physician’s professional service (see

§60.1);

• Commonly rendered without charge or included in the physician’s bill (see §60.1A);

• Of a type that are commonly furnished in physician’s offices or clinics (see §60.1A);

• Furnished by the physician or by auxiliary personnel under the physician’s direct

supervision (see §60.1B).

B - Institutional Setting

Hospital services incident to physician’s or other practitioner’s services rendered to outpatients

(including drugs and biologicals which are not usually self-administered by the patient), and partial

hospitalization and intensive outpatient services incident to such services may also be covered.

The hospital’s A/B MAC (A) makes payment for these services under Part B to a hospital.