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 his supervision, such as nurses,
nonphysician anesthetists, psychologists, technicians, therapists, including physical
therapists, and other aides. Thus, where a physician employs auxiliary personnel to
assist him in rendering services to his patients and includes the charges for their
services in his 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 his 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 her services. Direct, personal, and continuous supervision
does not require the anesthesiologist to be in the operating room at all times. However,
he 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 she 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 her services.
In both cases, the physician must include the charges for the anesthetist's services
in his bill and these charges will be taken into account in determining the physician's
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 his 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 his professional practice.
Supplies usually furnished by the physician in the course of performing his 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. See HI 00610.304 regarding the coverage of antigens.