Incident-To Billing in 2026: The Rules, the Risks, and the New Virtual-Supervision Change
Incident-to pays NP and PA services at 100% instead of 85% — but only when every condition is met, and it is a top audit target. Here are the rules, the 2026 virtual-supervision update, and how to stay clean.
Incident-to billing is worth exactly 15% — the difference between 100% of the fee schedule and the 85% an NP or PA earns under their own NPI. That gap is real money across a busy practice. It is also one of the most audited billing patterns in Medicare, so the discipline has to match the upside.
What incident-to actually is
Incident-to lets services furnished by auxiliary personnel — nurse practitioners, physician assistants, clinical staff — be billed under a supervising physician's NPI at 100% of the Medicare Physician Fee Schedule, rather than the 85% paid when the NPP bills under their own number. The trade for that extra 15% is a strict set of conditions.
The conditions — all must be true
- Established patient with an established plan of care the physician personally created.
- No new problems. A new complaint requires the physician to see the patient and reset the plan.
- Direct supervision — the physician (or another qualified physician in the group) is immediately available during the service.
- The service is an integral, though incidental, part of the physician's professional service.
New patient or new problem? It cannot be incident-to. That single rule prevents most incident-to audit findings.
2026: virtual direct supervision is now permanent
The big change: effective January 1, 2026, CMS permanently allows the "immediately available" element of direct supervision to be met by real-time audio/video presence (audio-only does not count) for most services. The physician no longer must be physically in the suite for those services. The exception: higher-risk procedures with 010 (minor, 10-day) or 090 (major, 90-day) global periods still require on-site physical presence.
Why auditors love incident-to
Because the 100% claim looks identical to a physician's own — until someone checks who actually rendered the care and whether the conditions held. Payer Special Investigations Units routinely probe it. The safe posture: when any condition is uncertain, bill under the NPP's NPI at 85%. A clean, documented policy is exactly what a strong revenue cycle and coding program enforces.
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The bottom line
Incident-to is legitimate revenue when every condition holds — established patient, established plan, no new problem, proper supervision. The 2026 virtual-supervision change adds flexibility, but the fundamentals (and the audit risk) remain. When in doubt, 85% under the NPP is the safe call. Want a compliance check? Start with a free billing audit.
Sources
Frequently asked questions
It is a Medicare Part B mechanism that lets services by auxiliary personnel (NPs, PAs, clinical staff) be billed under a supervising physician’s NPI at 100% of the fee schedule, instead of 85% under the NPP’s own NPI — but only when strict conditions are met.
No. Incident-to requires an established patient with a plan of care already established by the physician. A new patient, or an established patient with a new problem, cannot be billed incident-to.
Yes. Effective January 1, 2026, CMS made permanent the option to satisfy direct supervision through real-time audio/video (not audio-only) for most services. Certain higher-risk procedures with 010 or 090 global periods still require the physician’s physical, on-site presence.
Billing at 100% when the conditions were not met is a common target of payer Special Investigations Units and can lead to recoupments and penalties. When in doubt, bill under the NPP’s NPI at 85%.
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