"Incident to" services are defined as "services or supplies furnished as an integral although incidental, part of the physician's personal professional services'" (MCM 2050.1). The "incident to" provision also applies to coverage for psychological services furnished "incident to" the professional services of non-physician practitioners (Clinical Psychologists, Clinical Nurse Specialists). Section (a)(1)(A) of the Social Security Act governs payment for the provision of medical care to Medicare beneficiaries. It limits payment for medical services to those that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member." The training requirements and state licensure or authorization of individuals who perform psychological services are intended to ensure an adequate level of expertise in the cognitive skills required for the performance of diagnostic and therapeutic psychological services. Therefore, only the types of individuals listed later in this policy are considered qualified to perform medically necessary psychological services addressed in this policy. Delegation of diagnostic and therapeutic psychological services to personnel not performing within the cope of practice as authorized by state law, under the "incident to" provision, would bypass the safeguards afforded by professional credential and state licensure requirements. Such delegated services under the "incident to" provision would be inappropriate, unreasonable, and medically unnecessary, and therefore not covered by Medicare.

A. Only the following types of individuals, when they are performing within their scope of clinical practice as authorized under State law, are qualified to perform the indicated diagnostic an/or therapeutic psychological services under the "incident to" provision:

Illinois Only:

Licensed Clinical Professional Counselors (LCPCs): 90801, 90802, 90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, 90828, 90846, 90847, 90849, 90857, 90899

B. The psychological services references in the above HCPCS codes may be delegated only to employees who qualify for one of the four categories of individuals listed above. For example, a psychiatrist may hire a social worker to perform services"incident to", but the services the social worker may perform must be limited to the services designated by the HCPCS codes listed in #2 above. Individuals who are performing services "incident to" a qualified Medicare practitioner are not required to be separately enrolled as an independent practitioner in Medicare. Also, it is not possible for the billing provider to hire and supervise a professional whose scope of practice is outside the provider's own scope of practice as authorized under State law, or whose professional qualifications exceed those of the "supervising" provider. For example, a certified nurse midwife (CNMW) may not hire a psychologist and bill for that psychologist's services are not integral to a CNMW's personal professional services and are not regularly included in the CNMW's bill. Even though sections 1861 (s)(2)(L) and 1861 (gg) of the Social Security Act authorize coverage for services furnished "incident to" a CNMW's services, psychological services are not commonly furnished in CNMW's offices nor within their scope of practice. Similarly even thought section 186 (s)(2)(K)(iv) authorizes coverage for services furnished "incident to" a physician assistant's services, a physician assistant would not be qualified to supervise psychological services performed by the types of individuals listed above.

C. Individuals who are not licensed or otherwise authorized by state law to provide psychological services may not provide psychological service under the "incident to" provision. This level of professional credentialing is necessary to appropriately furnish medically necessary services under the "incident to" provision. Psychological services furnished to Medicare beneficiaries under the "incident to" provision by individuals other than those listed above are not covered. (Note: the standards for professional credentialing are higher for these services billed to Medicare Part B than for similar services performed by other mental health professionals not under the "incident to" provision and billed to Medicare Part A. Under the "incident to" provision, services are performed in the place of the billing provider. IN order for services performed and billed under the "incident to" provision to be commensurate with the services performed by the billing provider, and therefore medically necessary, this higher standard of professional credentialing is necessary.)

D. Medicare does not pay for routine screening tests. ICD-9-Cm code V82.9 (special screening of other conditions, unspecified condition) or comparable narratives should be used to indicate screening tests performed in the absence of a specific sign, symptom or complaint. Use of V82.9 or a comparable narrative will result in the denial of claims as non-covered screening services.

E. Reviewing results of laboratory tests, phoning results to patients, filing such results, and such activities as obtaining, reviewing and analyzing the appropriate diagnostic tests, are services which are covered by the Medicare program, but are included in payments for evaluation and management (E & M) services.

F. *CPT codes 90816 through 90829 cannot be billed as "incident to" in the inpatient hospital or partial hospital setting. These services are bundled into Part A payment. Also payment of social workers services in a Part A nursing home stay are also bundled into Part A payment. It would be very rare for supervisory or other "incident to" criteria to be met in the residential care settings.

Illinois

Date Published: 6/01/2000; Article 08/01/2000

*05/01/2002

Date Policy Became Effective:Existing regulations, 07/01/2000

Revision Date and Number: 06/16/2000, one; *05/01/2002, two (NCP Quadstate);

Contractor Name

Wisconsin Physicians Service (WPS)