Coverage of services and supplies “incident to” the professional services of a physician in private practice is limited to situations
in which there is direct physician supervision. This applies to services of auxiliary
personnel employed by the physician and working under the physician's supervision,
such as nurses, nonphysician anesthetists, psychologists, technicians, therapists,
including physical therapists, and other aides. Thus, where a physician employs auxiliary
personnel to assist the physician in rendering services to the physician's patients
and includes the charges for their services in the physician's own bills, the services
of such personnel are considered to be “incident to” the physician's services if there is a physician's service rendered to which the
services of such personnel are an incidental part and there is direct personal supervision
by the physician.
Direct personal supervision in the office setting does not mean that the physician
must be present in the same room with the physician's aide. However, the physician
must be present in the office suite and immediately available to provide assistance
and direction throughout the time the aide is performing services.
The services of a nonphysician anesthetist are covered under medical insurance when
the anesthetist is the employee of an anesthesiologist who provides direct, personal,
and continuous supervision of the anesthetist's services. Direct, personal, and continuous
supervision does not require the anesthesiologist to be in the operating room at all
times. However, the anesthesiologist must be close by and available to provide immediate
and personal assistance and direction. Availability of the anesthesiologist by telephone
does not constitute direct, personal, and continuous supervision. The services of
a non-physician anesthetist are also covered when the anesthesiologist is an employee
(either on a part- or full-time basis) of any surgeon (or other physician) who is
rendering professional services during the operative procedure and directing services.
In both cases, the physician must include the charges for the anesthetist's services
in the physician's bill and these charges will be taken into account in determining
the physician's reasonable charge.
Where auxiliary personnel perform services outside the office setting, e.g., in the
patient's home or in an institution, their services are likewise covered only if there
is direct personal supervision by the physician. For example, if a nurse accompanied
the physician on house calls and administered an injection, the services are not covered
(even when billed by the physician) since the physician would not be providing direct
personal supervision. Services provided by auxiliary personnel in an institution (e.g.,
hospital, SNF, nursing or convalescent home) present a special problem in determining
whether direct physician supervision exists. The availability of the physician by
telephone, and the presence of the physician somewhere in the institution would not
constitute direct personal supervision.
Services provided by auxiliary personnel not in the employ of the physician even if
provided on the physician's order or included in the physician's bill (e.g., an independently
practicing therapist who forwards a bill to the referring physician for inclusion
in the physician's statement of services) are not covered as incident to a physician's
service since the law requires that the services be of kinds commonly furnished in
physicians' offices and commonly either rendered without charge or included in physicians'
bills. As with the physician's personal professional service, the patient's financial
liability for the incidental services is to the physician; therefore, the incidental
services must represent an expense incurred by the physician in the physician's professional
practice.
Supplies usually furnished by the physician in the course of performing the physician's
services, such as gauze, ointments, bandages (including ace bandages), oxygen, etc.,
are also covered. Charges for such services and supplies must be included in the physicians'
bills. To be covered, supplies, including drugs and biologicals, must represent an
expense to the physician. For example, where a patient purchases a drug and the physician
administers it, the cost of the drug is not covered. Regarding the coverage of antigens,
see HI 00610.304.