Incident-To Billing for PMHNPs: When It Applies, When It Doesn't, and the Risks

Incident-to billing lets a PMHNP’s follow-up visits be billed under a supervising psychiatrist’s NPI in Medicare, paying 100% of the physician fee schedule instead of the 85% a nurse practitioner receives under their own NPI. It only applies when the psychiatrist started the course of treatment, stays actively involved, provides the required supervision, and the PMHNP is treating an established problem under the psychiatrist’s plan of care. New patients and new problems must be billed under the PMHNP’s own NPI.

Incident-to is one of the most misunderstood Medicare rules in psychiatry group practices. Used correctly, it is legitimate. Used as a default for every PMHNP visit, it is a common reason for audits and repayments.

The two ways a PMHNP visit can be billed to Medicare

	Under the PMHNP’s own NPI	Incident-to the psychiatrist
Medicare payment	85% of the physician fee schedule	100% of the physician fee schedule
Who must have started treatment	Anyone	The psychiatrist (or other supervising physician)
New patients and new problems	Allowed	Not allowed
Supervision	None required	Required (see below)
Setting	Any	Office or clinic setting, not hospital outpatient departments or facilities
Audit risk	Lower	Higher; every condition must be documented

When incident-to can apply

All of these must be true, and documented, for each visit:

1. The psychiatrist performed the initial service and established the diagnosis and plan of care.
2. The PMHNP is treating the same problem under that plan. A new diagnosis, or a significant change in the plan, brings the patient back to the psychiatrist.
3. The psychiatrist stays actively involved in the course of treatment, with periodic visits that show ongoing participation.
4. The PMHNP is employed or contracted by the practice or the psychiatrist.
5. Supervision rules are met. Medicare generally requires direct supervision for incident-to services. Since 2023, Medicare allows behavioral health services furnished incident-to by auxiliary personnel to be provided under general supervision, which means the supervising practitioner does not have to be physically present. Confirm with your Medicare contractor how the current supervision rules, including any rules for supervision by real-time audio and video, apply to the services your PMHNPs provide.
6. The service is in an office or clinic setting. Incident-to does not apply in hospital outpatient departments or facility settings.

When it does not apply

• New patients. The first visit must be with the psychiatrist, or billed under the PMHNP’s own NPI.
• New problems. A new condition for an existing patient needs the psychiatrist, or the PMHNP’s own NPI.
• Commercial and Medicaid plans, unless the plan’s written policy allows it. Many require NPs to be credentialed and bill under their own NPI.
• When the psychiatrist is not involved in the patient’s ongoing care.
• In facility settings, such as hospital outpatient departments.

Documentation that supports incident-to

• The psychiatrist’s initial visit note with the diagnosis and plan of care.
• PMHNP follow-up notes that refer to the psychiatrist’s plan and stay within it.
• Periodic psychiatrist visits or notes showing active involvement.
• The supervising practitioner’s name on each claim and in the record.
• Records showing the supervision rule that applied on the date of service.

If any of these is missing, bill the visit under the PMHNP’s own NPI.

Incident-to vs credentialing every PMHNP

Many psychiatry groups find it simpler, and safer, to credential each PMHNP with every payer and bill all of their visits under their own NPI. The 15% difference in Medicare payment is real, but so is the cost of an audit that takes back a year of incident-to payments. A common middle path: bill under the PMHNP’s own NPI by default, and use incident-to only for Medicare follow-ups where every condition is clearly met.

For more on prescriber billing, see billing 99214 with 90833 and our PMHNP credentialing guide.

This guide is general information, not legal advice. Medicare and payer rules change, so confirm current requirements in the CMS Medicare Benefit Policy Manual and the latest Physician Fee Schedule rule, and with each payer, before billing.

How RevenueCTRL can help

We bill for psychiatry and PMHNP practices and group practices, and we check which NPI each claim should go under before it is sent. If you are not sure your current incident-to billing would hold up in an audit, a free 90-day claims audit reviews your recent claims and tells you where the risks are.

Frequently asked questions