Definition

"Incident to" services are those that are performed by ancillary personnel under the supervision of a qualified Medicare provider. Services furnished "incident to" a psychologist's services are covered by Medicare if they meet specified requirements outlined in the Medicare Carriers Manual. These requirements state that the services must be:

1. mental health services that are commonly furnished in a psychologist's office;
2. an integral, although incidental, part of the professional services performed by the psychologist;
3. performed under the direct personal supervision of the psychologist; and
4. either furnished without charge or included in the psychologist's bill.

Furthermore, any person performing an "incident to" service must be a part-time, full-time, or leased employee of the "clinical psychologist" or an employee of the legal entity that employs the supervising "clinical psychologist".

A leased employee is a person working under a written employee leasing agreement which provides that:

• The ancillary personnel, although employed by the leasing company, provides services as a leased employee of the "clinical psychologist" (or the entity that employs the "clinical psychologist"); and
• The "clinical psychologists" (or their employer) exercises control over all actions taken by the leased employee with regard to the services the leased employee renders to the same extent as the "clinical psychologist" (or their employer) would exercise such control if the leased employee were directly employed by the "clinical psychologist" or the entity that employs the "clinical psychologist."

Qualifications of Ancillary Personnel

National policy does not specify the level of training or education necessary for those providing the "incident to" service. For example, these ancillary personnel could be psychology technicians, Masters level psychologists, psychology interns, or even psychologists working to complete a post-doctoral fellowship. However, there appears to be movement from local carriers to set forth certain qualification standards.

Specifically, some Medicare carriers have implemented local medical review policies (LMRPs) stating that only doctorate or masters level psychologists "when they are performing within their scope of clinical practice as authorized under State law," are qualified to perform therapeutic psychological services under the "incident to" provision. This means that, even when performing such services "incident to" a qualified "clinical psychologists" a certain level of licensure is required in order for these services to be covered by Medicare. Because these requirements are not national requirements and are only present in LMRPs, it is important to check with your local carrier to see if such restrictions exist.

Billing "Incident To" Services for Hospital Patients

HCFA issued clarification in October of 1996²² stating that all "incident to" services provided to hospital inpatients or registered hospital outpatients are bundled services. According to HCFA's Hospital Manual, a hospital outpatient is a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services from the hospital. Therefore, while services provided directly by the qualified "clinical psychologists" are not bundled and are billed directly to Part B for reimbursement, the time spent by ancillary personnel (i.e., MAs, psychometrists, pre-doctoral interns and post-doctoral fellows) can only be billed by the hospital.

Supervision of "Incident To" Services

Present instructions for supervision of these services vary depending on place of service. In an office setting, the psychologist must be "somewhere in the office suite and immediately available." In an institution, however, the level of supervision is more vague. National policy states only that "being available by telephone or somewhere in the institution would not constitute direct personal supervision." Several carriers have developed more stringent requirements, particularly in Skilled Nursing Facilities (SNFs). Many of these carriers are requiring "in the room" or "over the shoulder" supervision for institutional settings. Although "incident to" services provided to hospital patients cannot be billed to Medicare Part B, this does not eliminate the "incident-to" supervision requirements.

Graduate Medical Education (GME)

Unlike psychiatry internship programs, psychology interns do not currently receive GME funding. We expect that to change in the very near future. When we are successful in attaining GME funding for our programs, it is possible that more restrictive supervision requirements may be required. Current psychiatric residency programs require the teaching physician to be present during the "key portion" of any service in which a resident is involved. This would require either direct observation of the service, or use of a one-way mirror or video equipment.²³ Check with our Government Relations office to learn the latest news regarding GME.

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