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Proposal To Change Coding Associated With “Incident To” Billing


It is evident that healthcare systems across the globe in both developed and under-developed are evolving and changing rapidly. Nurses are a significant part of health systems, and as such, it is essential if they were to adopt and embrace the changes. For nurses to fully accept the changes, it is indispensable for all nurses across the globe to be involved in the formulation of health policies rather than just concentrating in the implementation stage (Arabi, Rafil, Cheraghi, & Ghiyasvandian, 2014). Since nurses work on a one-to-one basis with the patients, their influence on healthcare policies works not only to improve quality of care but also facilitate the access of resources and systems that are intended to enhance the delivery of care. A case in point is the “incident to” billing which currently works to demotivate nurses and as such adversely affecting their job satisfaction and subsequently performance.

Proposed Change: Change how the “incident to” billing is coded

In particular circumstances, the Centers for Medicare and Medicaid Services (CMS) guidelines allow doctors to utilize their provider numbers to bill for healthcare services that were provided by a nurse practitioner (NP). This is what is referred to as “incident to” billing the physician’s diagnosis (Verhovshek, 2016). However, since the doctors are reimbursed at a relatively higher rate compared to the nurses, there is an incentive to utilize the “incident to” system. The CMS does not have a method for accounting for who provides which service since it does not mandate that it should be identified in the claims for reimbursements. Therefore, since the physicians do not provide information on the contributions of NPs it is difficult for policymakers, researchers, the government and the society as a whole to quantify the efforts of nurses. The current way in which the incident to billing is coded ignores and undermines the Medicare Access and CHIP Reauthorization Act (MACRA) goals that focus on rewarding healthcare providers on the grounds of value-based care (Buerhaus et al., 2018). Therefore, there is a necessity to change the way the billing is done to reward both the physicians and the nurse practitioners according to the recommendations of MACRA.

Agenda Setting Strategies

In efforts of promoting the support of various stakeholders in the healthcare sector, it is essential to acknowledge the importance of incident to billing and how it is associated with the number of healthcare services delivered by doctors across the country. A research on the billing patterns in two types of states, where one allows NPs to practice independent of physicians and another where NPs are mandated to work with doctors hypothesized that the billing rates in states that nurses practice independent of physicians are lower since the nurses will not bill under the physicians (Buerhaus et al., 2018). Utilizing data from Medicare beneficiaries attended to by physicians, data from the Healthcare Common Procedure Coding System (HCPCS) and payment received by physicians, researchers concluded that physicians employed in states that mandate the supervision of NPs in billing seem to be more involved in the Medicare program (Buerhaus et al., 2018). Based on the results of similar research, it is easy to prompt support from different stakeholders including patients, policymakers, the government and society as a whole. Ultimately, seeking assistance from the various stakeholders depends on the ability to showcase the importance of incident to billing and its mechanisms including how it relates to healthcare services that physicians deliver and how they are subsequently involved in Medicare services.

A theory that can be utilized to bring the Change

In recent years, the philosophy of value-based care under the economic theory of agency continues to gain popularity not only in developed countries but also in developing countries. There are many elements associated with value-based care as a patient-centric approach to health delivery including data and health informatics, research and evidence-based practice, improvement in healthcare management and incentives and payments (Conrad, 2015). Under incentives and salaries, it is necessary for remuneration models to take into account both volume and quality and uphold priorities and goals that focus on compartmentalized spending. Indeed, the attractiveness of value-based care has influenced some recalibrated compensation such as fee-for-service, capitation also known as global payment and bundled payment among others. The case for changing the billing system associated with the incident to billing strategy rests on the idea that NPs deserve recognition and compensation for their contribution in the delivery of healthcare.

Design Strategies

In the USA, there are more than 235,000 nursing practitioners. Medicare reimburses NPs at 85 percent of the prevailing rates of physicians for the provision and delivery of a similar service. The incident to billing was initially formulated with the intention of managing operating costs particularly in cases where a physician is working with NPs and PAs (Nelson, 2012). Research indicates while a considerable of nurses utilize their own NPI, more than 80 percent of nurses reported incidents where they worked with physicians as such allowing for the incident to billing (Buerhaus et al., 2018). Specifically, more than 20 percent of NPs and ten percent of physicians reported that various NP services are billed through the incident to billing system.

The incident to billing adversely influences the claims-based assessment regarding quality whether it is delivered by a clinician, a nurse or a physician. It is necessary for each service in the healthcare system to be attributed to the individual that provided in efforts of accurately quantifying quality. Apart from affecting quality assessment, incident to billing affects costs of care and number of working hours for a clinician (Mahooti, 2014). The system hides the contribution of NPs thus preventing NP leaders in addition to policymakers and the general public from having complete information during the formulation of policies and the subsequent negotiations of payment. Therefore, it is deductible that NPs provide higher quality service at lower costs. If the practice is omitted or at least changed in such a way that NPs can account for their contribution, it will allow for a more transparent assessment of both quality and costs associated with care provision and delivery.

Implementation Strategies

The incident to billing problem can be remedied if Medicare was to adjust its billing systems to allow nurses to take credit for their contribution. It encompasses the CMS changing the current coding activities in efforts of assisting and facilitating accurate measurement concerning both quality and cost of care that Medicare beneficiaries in healthcare facilities across the USA (Future Health Index, 2018). Primarily, the implementation stage encompasses CMS modifying their current billing procedures so that each clinician is linked to the service, test or system that he or she delivered.

Evaluation Strategies

Evaluation encompasses activities that determine the success of a particular intervention. Assessment strategies will include evidence that each clinician is recognized for his or her efforts. Specific evaluation will illustrate that each bill under their code instead of nurses relying on physicians for procedures that they accomplished together (Khullar et al., 2015). In the event, both the NP and the Physician were involved in a particular procedure; it is necessary for the bill to Medicare to showcase the role of each.


The efforts of paying a clinician according to the service delivered are the backbone of the value-based payment system postulated by the MACRA. Since remuneration is a critical aspect of an individual’s job satisfaction, morale and subsequently performance, it is essential for healthcare systems across the globe to be conscious of nurses’ compensation rates. Over the past two decades, the CMS has made evident progress in addressing the issue of incentive and payment from the outdated fee-for-service to the current value-based technique. Therefore, it is essential that incident to billing is changed to remain true to its efforts value-based care and to recognize nurses for their dedication to the provision of care.


Arabi, A., Rafil, F., Cheraghi, M. A., & Ghiyasvandian, S. (2014). Nurses’ policy influence: A Concept analysis. Iranian Journal of Nursing and Midwifery Research, 19(5), 536-543.

Buerhaus, P., Skinner, J., McMichael, B., Auerban, D., Perloff, J., Staigar, D., & Skinner, L. (2018, January 8). The integrity of MACRA may be undermined by “Incident to billing” coding. Retrieved from Health Affairs:

Conrad, D. (2015). The theory of value-based payment incentives and their application to health care. Health Services Research, 2057-2089.

Future Health Index. (2018, January 26). The four pillars of a value-based healthcare future. Retrieved from Phillips News Center:

Khullar, D., Chokshi, D. A., Kocher, R., Reddy, A., Basu, K., Conway, P. H., & Rajkumar, R. (2015). Behavioral economics and physician compensation- Promise and Challenges. New England Journal of Medicine, 372(24), 2281-2284.

Mahooti, T. (2014). Modeling and analysis of value-based healthcare delivery. Wilfrid Laurier University Thesis and Dissertations.

Nelson, L. (2012). Lessons from Medicare’s demonstrations projects on value-based payment. Working Paper Series 2012-02 Washington DC; Congressional Budget Office.

Verhovshek, J. G. (2016, November 24). The basics of incident-to-billing. Retrieved from Physicians Practice:


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