- Incident-to requires all four: care integral to the physician's established plan, direct supervision in the office suite, a follow-up for an existing problem rather than a new one, and a service that is part of routine physician care.
- A new complaint the physician has never evaluated breaks incident-to for that visit. Code it under the APP at 85 percent, or have the physician step in, evaluate it, and document that involvement.
- Incident-to is an office concept only. In hospital inpatient and outpatient settings the APP always codes under their own NPI, regardless of supervision.
- The 85 percent adjustment is applied downstream by the payer. An APP selects the code and documents the visit exactly as a physician does; a 99214 carries the same wRVU whoever performed it.
Same code, same wRVU, different check
When an APP sees a Medicare patient, the practice can code the visit under the APP's own national provider identifier at 85 percent of the physician fee schedule, or, when a specific set of conditions is met, "incident to" a physician under the physician's number at 100 percent. That gap is why incident-to exists and why it draws audit attention. It says nothing about the APP's skill; it is purely about whose number the claim goes out under.
Incident-To: When an APP Visit Codes Under the Physician
All four requirements must hold at once.
The Four Requirements for Incident-To Coding
- The care must be integral to the physician's own treatment plan. The coding physician, not just any physician in the group, must have personally seen the patient, diagnosed the problem, and set the plan the APP is now carrying out.
- Direct supervision is required. For office-based incident-to, the physician must be in the office suite and immediately available, not just in the building or reachable by phone. For 2026, Medicare generally allows the physician's real-time audio and video presence to meet direct supervision for eligible incident-to services; services with 010 or 090 day global indicators and certain others still require physical presence. Confirm your payer's position before relying on virtual presence.
- This particular visit must be a continuation, not a new problem. Requirement 1 is the relationship; this one is the encounter being coded: a follow-up for a problem already evaluated and under an existing plan. A new problem, or a plan change that amounts to a fresh physician evaluation, takes that part of the visit out of incident-to.
- The service must be included in the physician's standard of care. It must be the type of service typically provided as part of physician care in that setting.
The New-Problem Trap
Requirement 3 fails mid-visit. An established patient comes in for an APP-managed follow-up and raises a complaint the physician has never evaluated. Coding the whole visit incident-to at 100 percent is non-compliant, because no physician plan exists for the new problem.
Incident-To Does Not Apply in Hospital Settings
Incident-to is an office concept only. In hospital inpatient and outpatient settings, APPs always code under their own NPI, regardless of physician supervision. The split/shared visit is a separate construct with its own requirements, including the FS modifier, covered in the hospitalist coding guide.
The State Scope-of-Practice Interaction
Incident-to is a Medicare coding rule, not a scope-of-practice rule. State independent practice authority answers whether the APP may see the patient alone; incident-to answers whose number the claim goes out under. One does not change the other.
Documentation That Makes Incident-To Defensible
Document three things: the physician's initial evaluation and plan, the APP's follow-up note explicitly referencing that plan, and the supervising physician's presence in the suite during the visit. Co-sign APP notes consistently, not selectively. If any element is missing, code under the APP.
Advanced Practice Providers: The 85 Percent Rule and What It Means
Under an APP's own national provider identifier, Medicare pays 85 percent of the physician fee schedule. The work and the code are identical; a 99214 generates the same wRVU whoever performed it, but the dollars differ by whose number is on the claim.
| Coding pathway | Whose NPI | Medicare pays | When it applies |
|---|---|---|---|
| APP's own number | The APP | 85 percent of the physician fee schedule | Always allowed, in any setting |
| Incident-to | The supervising physician | 100 percent | Office only; all four requirements above must be met |
| Split/shared | The physician | 100 percent | A visit genuinely shared between physician and APP and coded under the physician, with its own rules |
That gap is why incident-to and split/shared exist, and why auditors look for physician-rate claims where the requirements were not met. Physician assistants historically could not bill Medicare directly at all; the rules have evolved, but the coding arrangement, not the clinical work, determines the payment.
What This Means for an APP
Everything on this site applies to you; the 85 percent adjustment is applied downstream and changes nothing about how you select a code or what you document. Whether the visit goes out under your NPI or a physician's is a practice-level decision under the incident-to and split/shared rules that affects the value attributed to your work, so know how your group handles it.
A Note for Practices
Incident-to and split/shared recover the fifteen percent only when the requirements are met. Build workflows that satisfy and document them, or accept the 85 percent. APP follow-ups scheduled on days the supervising physician is in the suite, the initial evaluation and plan kept easy to find, and new complaints routed to the physician in real time turn a risky 100 percent into a defensible one.
Sources and Further Reading for This Chapter
- AAFP, incident-to and shared services coding. https://www.aafp.org/pubs/fpm/issues/2024/0500/shared-services-coding.html
- CMS, Physician Fee Schedule. https://www.cms.gov/medicare/payment/fee-schedules/physician
- MedPAC, payment policies for advanced practice providers. https://www.medpac.gov/