Question 1

What is physician billing, and how is it different from facility billing?

Accepted Answer

Physician billing, also called professional billing, covers the fee for a provider's own clinical work, their evaluation, medical decision-making, and any procedures they personally performed or directly supervised, submitted on a CMS-1500 form or its electronic equivalent, the 837P transaction. Facility billing is a genuinely separate process, covering the room, staff, equipment, and overhead a hospital or ambulatory surgery center provides, submitted on a UB-04 form or the 837I transaction. These aren't two names for the same thing. A physician seeing a patient in a hospital generates two entirely separate claims for that single encounter, the physician's own professional fee claim and the hospital's facility claim, adjudicated under different payment systems entirely.

Question 2

What is incident-to billing, and when does it actually apply?

Accepted Answer

Incident-to billing allows a non-physician practitioner's service, an NP or PA, to be billed under a supervising physician's NPI at 100 percent of the fee schedule rather than 85 percent under the practitioner's own NPI. The requirements are specific: the service has to continue an established plan of care that the physician personally initiated, and the physician has to be physically present in the office suite while the service is furnished. A new patient encounter can never qualify for incident-to billing, because there is, by definition, no established plan of care yet for a physician to have initiated. This is a structural disqualifier, not a documentation detail that can be worked around.

Question 3

What is split/shared billing, and how is it different from incident-to?

Accepted Answer

Split/shared billing is a separate rule from incident-to, applying specifically in facility settings, a hospital, most commonly, rather than the office. It determines which provider's NPI bills the visit when a physician and a non-physician practitioner each perform a substantive portion of the same encounter, and that determination is generally based on which provider actually performed more than half of the total time spent on the encounter. Unlike incident-to, split/shared billing has nothing to do with an established plan of care or physician office presence, because the entire rule exists specifically to cover facility encounters where incident-to's office-based framework doesn't apply at all.

Question 4

Can a physical therapist bill incident-to a physician?

Accepted Answer

Not in the way standard incident-to billing typically works for physician office staff. Physical therapy services generally operate under their own specific billing framework, tied to a therapy plan of care and its own certification and documentation requirements, distinct from the standard incident-to rules that apply more narrowly to auxiliary clinical staff working under a physician's direct supervision. A licensed physical therapist delivering therapy services under their own plan of care isn't the same billing situation as, for example, a medical assistant performing a service directly incident to and under the immediate direction of a physician's own encounter. Treating physical therapy billing as a simple variant of standard incident-to rules blurs two genuinely different frameworks that have their own separate requirements.

Question 5

What is locum tenens billing, and when can it be used?

Accepted Answer

Locum tenens billing, using modifier Q5 for a reciprocal billing arrangement or Q6 for a fee-for-time compensation arrangement, allows a practice to bill a substitute physician's services under the regular physician's own NPI, but only within specific, time-limited circumstances tied to a genuine reason the regular physician is unavailable, illness, vacation, continuing education, military leave, among others. This is not intended as a general-purpose way to bill for a newly hired physician who is still waiting on their own payer enrollment to be completed, even though the underlying situation, a new person seeing patients before their own billing number is active, can look superficially similar. Using locum tenens modifiers outside their actual eligibility circumstances is a real compliance risk, not a convenient workaround for a credentialing gap.

Question 6

Can copays be waived as a professional courtesy?

Accepted Answer

This carries more compliance risk than it might initially seem to, and it's worth understanding clearly rather than treating as a purely administrative courtesy. Waiving copays, coinsurance, or deductibles routinely, as a matter of general practice policy rather than a genuine, case-by-case financial hardship determination, can create exposure under the Anti-Kickback Statute, because a routine waiver can function as an inducement to receive services rather than a legitimate courtesy. A financial hardship waiver, documented and determined individually for a specific patient's actual circumstances, is a different situation entirely from a blanket policy of waiving copays as a matter of course. Practices considering any copay waiver policy should understand this distinction clearly before implementing one broadly.

Results-Driven Physician Billing Company

What's Included

E/M Documentation and Coding Support

Incident-To Billing Compliance

Split/Shared Billing in Facility Settings

Locum Tenens Billing

Same-Group Billing Coordination

Claim Submission and Denial Management

Credentialing Coordination

Get in Touch for Physician Billing Services

Why Choose Us for Physician Billing Services?

Documentation and Coding Review

Provider Attribution Verification

Tech-Driven Solutions

Claim Submission

Reporting

Denial Management

24/7 Support Across All Specialties

Cardiology

Oncology

Neurology

Orthopedics

Radiology

Pediatrics

Urology

OB/GYN

Anesthesiology

Nephrology

Behavioral Health

Gastrology

TESTIMONIALS

Get Physician Billing That Actually Applies the Right Rule to the Right Setting

Frequently asked questions