**Abstract:**  
  
 _"Incident to" a physician's professional services means that the services or
supplies 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._ (CMS Pub 100-02, Chapter 15, Section 60.1)
The "incident to" provision may also apply to coverage for psychological
services furnished "incident to" the professional services of certain non-
physician practitioners including clinical psychologists, clinical social
workers, nurse practitioners, and clinical nurse specialists (CMS Pub 100-02,
Chapter 15, Section 60.2). Section 1862(a)(1)(A) of the Social Security Act
governs payment for the provision of medical care to Medicare beneficiaries.  
  
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 scope of practice as authorized by state law, under
the "incident to" provision, would bypass the safeguards afforded by
professional credentialing 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.  
  
_Coverage of services and supplies "incident to" the professional services of
a physician in private practice is limited to situations in which there is
direct physician supervision of auxiliary personnel._ (CMS Pub 100-02, Chapter
15, Section 60.2). To be considered an employee (auxiliary personnel) for
purposes of this section, the nonphysician performing an "incident to" service
is defined as _any individual who is acting under the supervision of a
physician, regardless of whether the individual is an employee, leased
employee, or independent contractor of the physician or legal entity that
employs or contracts with the physician._ (CMS Pub 100-02, Chapter 15, Section
60.2).  
  
**Indications and Limitations:**  
  
For psychology services rendered under the "incident to" provision, the
billing provider must first evaluate the patient personally and then initiate
the course of treatment. The appropriately trained therapists may then render
psychological services to the patient under the billing provider's direct
supervision.  
  
Only the types of practitioners listed below, when they are performing within
their scope of clinical practice as authorized under state law, are qualified
to perform the indicated diagnostic and/or therapeutic psychological services
under the "incident to" provision.

  * Doctorate or Masters level Clinical Psychologist: 90785, 90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, 90828, 90832-90834, 90836-90840, 90846, 90847, 90849, 90853, 90857, 90880, 90899. (Codes 90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, and 90828 were deleted effective 12/31/12.)  
  

  * Doctorate or Masters level Clinical Social Worker: 90785, 90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, 90828, 90832-90834, 90836-90840, 90846, 90847, 90849, 90853, 90857, 90899. (Codes 90804, 90806, 90808, 90810, 90812, 90814, 90816, 90818, 90821, 90823, 90826, and 90828 were deleted effective 12/31/12.)  
  
  

  * Clinical Nurse Specialist (CNS): 90785, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90832-90834, 90836-90840, 90846, 90847, 90849, 90853, 90857, 90899 (90862, if authorized by the state to prescribe medication; this code was deleted effective 12/31/12. 90863, if authorized by the state to prescribe medication.) Note: Codes 90804-90829 and 90857 were deleted effective 12/31/12  
  

  * Nurse Practitioner* (NP): 90785, 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813, 90814, 90815, 90816, 90817, 90818, 90819, 90821, 90822, 90823, 90824, 90826, 90827, 90828, 90829, 90846, 90847, 90849, 90853, 90857, 90899 (90862, if authorized by the state to prescribe medication; this code was deleted effective 12/31/12. 90863, if authorized by the state to prescribe medication.) Note: Codes 90804-90829 and 90857 were deleted effective 12/31/12  
  
*limited to advanced registered nurse practitioners with a masters degree in the mental health equivalent to a masters prepared certified clinical nurse specialist.
  * The psychological services referenced in the above HCPCS codes may only be delegated to employees who qualify for one of the categories of individuals listed above. For example, a psychiatrist may hire a clinical social worker to perform 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.   
  
It is not permissible 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 (CNM) may not hire a psychologist and bill for that psychologist's
services under the "incident to" provision, because a psychologist's services
are not integral to a CNM's personal professional services and are not
regularly included in the CNM's bill. Even though sections 1861(s)(2)(l) and
1861(gg) (l) of the Social Security Act authorize coverage for services
furnished "incident to" a CNM's services, psychological services are not
commonly furnished in CNM's offices nor within their scope of practice.
Similarly, even though section 1861(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.  
  
Individuals who are not licensed or otherwise authorized by state law to
provide psychological services may not provide psychological services under
the "incident to" provision. This level of professional credentialing is
necessary to furnish appropriate 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.)  
  
The practice of "marriage and family therapy" includes the identification and
treatment of cognitive, affective and behavioral conditions related to marital
and family dysfunctions that involve the professional application of
psychotherapeutic and systems theories and techniques in the delivery of
services to individuals, couples, and families. Local laws regulating their
professional practice do not authorize any licensed marriage and family
therapist or marriage and family therapy associate to administer or interpret
psychological tests. Please refer to applicable state laws.  
  
_Coverage of services and supplies "incident to" the professional services of
a physician in private practice is limited to situations in which there is
direct physician supervision of auxiliary personnel._ (CMS Pub 100-02, Chapter
15, Section 60.2). This also applies to the services of certain non -
physician practitioners who are being licensed by the states under various
programs to assist or act in the place of the physician, including nurses,
clinical psychologists, clinical social workers and other therapists. _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_ (CMS Pub
100-02, Chapter 15, Section 60.1 - Section 60.3). _Services and supplies
incident to a physician 's service in a physician directed clinic or group
association are generally the same as those described for the office setting_
(CMS Pub 100-02, Chapter 15, Section 60.3).  
  
For hospital patients and for SNF patients who are in a Medicare covered stay,
there is no Medicare Part B coverage of the services of physician-employed
auxiliary personnel as services incident to physicians' services under _
1891(s)(2)(A)_ of the Act. Such services can be covered only under the
hospital outpatient or inpatient benefit and payment for such services can be
made to only the hospital by a Medicare intermediary (CMS Pub 100-02, Chapter
15, Section 60).  
  
For "incident to" services to be covered when a physician's office is in an
institution, the _auxiliary medical personnel must be members of the office
staff rather than of the institution's staff, and the cost of supplies must
represent an expense to the physician's office practice. In addition, services
performed by the employees of the physician outside the "office" area must be
directly supervised by the physician; his presence in the facility as a whole
would not suffice to meet this requirement. (In any setting, of course,
supervision of auxiliary personnel in and of itself is not considered a
"physician's professional service" to which the services of the auxiliary
personnel could be an incidental part, i.e., in addition to supervision, the
physician must perform or have performed a personal professional service to
the patient to which the services of the auxiliary personnel could be
considered an incidental part). Denials for failure to meet any of these
requirements would be based on 1861(s)(2)(A) of the Act._ (CMS Pub 100-03;
_Medicare National Coverage Determinations Manual_ , Chapter 1, Part 1, 70.3)  
  
 _If auxiliary personnel perform services outside the office setting, e.g., in
a patient's home or in an institution (other than a hospital or SNF), their
services are covered incident to a physician's service only if there is direct
supervision. The availability of the physician by telephone or the presence of
the physician somewhere in the institution does not constitute direct personal
supervision_ (CMS Pub 100-02, Chapter 15, Section 60.1).