Incident-To Billing for Physician Assistants: How It Affects Your Production Report
Part 2 of a two-part series. Part 1 covered surgical PAs and the assist modifiers.
Last week I showed surgical PAs the codes that decide whether their work shows up as revenue. This week is for non-surgical PAs in clinic, facilities and hospital settings, and the mechanics are different.
Incident to billing for physician assistants is the provision that lets a practice submit your visit under a physician’s NPI and get paid 100% of the fee schedule instead of 85%. It is legitimate. It is common. And it may be a large reason your production report and your schedule describe two different jobs.
Your production report is not a record of what you did. It is a record of what got attributed to you.
What is Incident to Billing?
Incident to billing is a Medicare provision that lets a practice submit services you performed under your supervising physician's National Provider Identifier, and be paid at the physician rate. It applies in the office and clinic setting only. It exists because Medicare pays a claim submitted under a PA's own NPI at a lower rate than the same claim submitted under a physician's.
Key Aspects of Incident to Billing
Physician involvement: the physician, or another physician in the practice, must be available to you while you deliver the service. Current AAPA guidance describes that availability as two-way audio-visual communication, not necessarily physical presence in the office suite.
Established patient relationship: the physician must have already seen the patient, established the diagnosis, and started the treatment plan. You are continuing their plan, not opening a new one.
Scope of practice: the service has to sit inside your scope under state law, your practice agreement, and facility policy.
No special code: there is no incident-to code and no incident-to modifier. The claim simply goes out under the physician’s NPI. That is exactly what makes the work impossible to trace back to you.
Why practices use it
It pays more. 100% of the fee schedule instead of 85%, on the same visit.
It uses the team properly. Patients get seen sooner because you can carry the follow-up visits.
It keeps care continuous. The plan stays with the practice instead of restarting.
None of that is sinister. A practice that meets every condition and bills incident-to is using a pathway CMS built on purpose.
However, I need you to understand that this is also where your practice revenue contributions go to die. The second your work is billed under your supervising physician’s NPI, your production shows zero.
It is my goal that every PA know how to quantify their own contributions to the practice they work for so that they understand that they are a revenue producing asset to their practice, not necessarily always a cost.
Since as PAs many things are not billed under our own NPIs, our production reports are typically not a true reflection of the quantitative and qualitative value we bring to a practice.
By the end of this you will know how to quantify the value you bring to your practice.
The 15 point spread that drives everything
Start here, because every other fact in this post is downstream of it.
Medicare covers your services in all practice settings at 85% of the physician fee schedule when the claim goes out under your own NPI. Claims are submitted at the full physician charge; it is your NPI that tells the contractor to pay 85%.
Billed incident-to, the same visit pays 100%, and the claim is submitted under the supervising physician’s NPI.
That is a 15 point spread on every qualifying visit you see. No practice is neutral about 15 points. Which means the billing decision is usually made for you, by finance, before you ever meet the patient.
If you want to run your own numbers as you read, my Clinic PA Revenue Estimator walks through it step by step.
Incident-to: the six conditions, and all six must be met
This is not a preference. It is a test, and failing any one part of it means the visit must be billed under your NPI at 85%.
The service is performed in a medical office or clinic. Place of service 11 or 50 only.
The physician personally furnished a professional service, established the diagnosis, and initiated the treatment plan. Meaning, the SP did the first consult.
Your service is care related to the course of treatment the physician initiated. In practice, an established patient with an established problem. Meaning you can bill incident to for follow ups.
The physician, or another physician in the practice, is available via two-way audio-visual communication.
The physician remains responsible for overall care and sees the patient at a frequency reflecting active, ongoing participation.
You represent a direct financial expense to the billing physician (W-2, leased employee, or independent contractor) or share the same tax ID.
Three scope limits people get wrong:
It does not apply in hospital inpatient, outpatient, or facility settings.
It does not apply to commercial payers, Medicare Advantage, or Medicaid unless that payer’s policy specifically says so.
Some Medicare contractors add their own requirements, and several recommend documentation showing the billing physician was present, plus a co-signature.
Having a physician review or co-sign a patient’s chart, or discuss a patient with a PA, does not allow the service to be billed under the physician’s name.
That line is from AAPA, and it is worth reading twice. A co-signature is not a billing qualification. If a practice is audited, auditors look for verification that all six conditions were met on claims where a PA’s work went out under a physician’s NPI.
And when you are not billing incident-to: you may see new patients and established patients with new problems, and no physician has to see the patient or be on site unless your state law or facility policy requires it. But it is paid at 85% of the Physician's fee.
Split (or shared) visits: the same trade, in the hospital
Incident-to stops at the clinic door. In hospital inpatient, outpatient, observation and emergency settings, the equivalent provision is the split (or shared) visit, and it does the same thing: it routes a shared encounter to a physician’s NPI at 100% instead of yours at 85%.
The conditions:
Evaluation and management services only. Never procedures.
You and the physician work for the same group.
You both provide the service on the same calendar day. Not within 24 hours, the same date. You do not have to see the patient at the same time.
The physician performs a substantive portion of the service.
Either you or the physician has a face-to-face encounter with the patient.
The physician signs and dates the medical record.
For 2024 and beyond, substantive portion means more than half the total time spent on the service, counting your time and the physician’s time combined.
How to find out how your visits are actually being billed
You almost certainly do not know, and that is not your fault. Here is how to find out in one afternoon.
Pull your own schedule for a typical month and count your visits by type: new patients, established patients with established problems, established patients with new problems.
Ask your billing department which of those went out under your NPI and which went out under a physician’s. Ask by email.
Count the incident-to eligible ones. Established patient, established problem, physician-initiated plan, office setting. Those are the visits where the 15 point spread applies.
Multiply. Take the allowed amount for your most common codes, calculate 15% of it, and multiply by the number of qualifying visits in a year. That is the annual value the incident-to provision produces on your work.
That last figure is not money you are owed. It is money the practice earns because of how your work is billed, and it exists whether or not it shows up in your production reports. Knowing it changes the shape of every conversation that follows.
The lost attribution of PA productivity costs more than a paycheck
AAPA is direct about this, and it is worth quoting rather than paraphrasing:
Billing for medical services provided by a PA under the name of the physician creates a lack of transparency in the billing process that could have negative consequences for PAs in programs such as MIPS. The result is PA care and productivity that is "hidden" or not reported within the Medicare claim systems and databases. A PA cannot be evaluated on care quality metrics when the care he or she delivers is attributed to another professional.
Read that last sentence again. This is not only about compensation. When your work is attributed to someone else, you cannot be scored on quality metrics at all. Your MIPS record, and what shows up on public comparison sites like Medicare Care Compare, reflects care you did not deliver and omits care you did.
That is a career record problem, not a paycheck problem, and it compounds silently over years.
The ask that works, and the one that doesn’t
Here is where most PAs, once they learn about the 15 point spread, go wrong.
The instinctive ask is: bill under my NPI so I get the credit.
That ask loses. You are asking your practice to voluntarily take a 15% revenue cut on every qualifying visit you see, so that an internal report looks different. No employer says yes to that, and asking marks you as someone who does not understand the business you work in.
The ask that works is: keep billing incident-to, and credit me internally with the production I generated.
Nothing about the claim changes. The practice keeps its 100%. You are not asking for money to move. You are asking for the internal ledger to reflect who did the work, so that your compensation conversation happens against real numbers instead of a report built to leave you out.
Use this information to negotiate with numbers that make it make sense to keep you.
The point
Your production isn’t what you bill. It’s what you bill plus what you make possible.
Incident-to is a legitimate CMS pathway with six strict conditions, and a practice that uses it correctly is doing nothing wrong. It is genuinely good for practice financial health. It also hides your monetary contribution, because the payment rules were never built to make a PA’s contribution legible, and the 15 point spread guarantees the system will keep routing your work under someone else’s number.
The report will never show you what you generated. You have to bring that number yourself.
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