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What is incident-to billing?
It is a Medicare rule that lets the supervising practitioner bill, under their own NPI, for services their staff provide as part of the practitioner's care. The staff member's work is billed as if the practitioner did it.
- The service must be an "integral, though incidental, part" of the practitioner's care, and of a kind commonly provided in an office or clinic. [1]
- Only the supervising practitioner may bill for it, and the supervisor does not have to be the clinician treating the patient more broadly. [1]
- The staff member can be an employee, a leased employee or an independent contractor, and must meet the state's licensing rules. [1]
- It applies outside hospitals and skilled nursing facilities only. [1][4]
Who can bill incident-to, and who cannot?
Physicians, clinical psychologists, nurse practitioners, clinical nurse specialists, physician assistants and certified nurse-midwives can. Social workers, counselors and marriage and family therapists can work under someone else's incident-to billing, but cannot bill incident to their own services.
| License | Can supervise and bill incident-to? | Can work as the staff member? |
|---|---|---|
| Physician, including psychiatrists | Yes | Yes |
| Clinical psychologist | Yes | Yes |
| Nurse practitioner, including PMHNPs | Yes | Yes |
| Clinical nurse specialist, physician assistant, certified nurse-midwife | Yes | Yes |
| Clinical social worker (LCSW) | No | Yes |
| Mental health counselor (LPC, LMHC) | No | Yes |
| Marriage and family therapist (LMFT) | No | Yes |
- CMS says it does not cover services provided incident to a marriage and family therapist's, mental health counselor's or clinical social worker's own services. [4][7]
- LCSWs, mental health counselors and MFTs can enroll in Medicare and bill on their own NPI instead. MFTs and counselors have been able to since January 1, 2024, and are paid 75% of what a clinical psychologist gets. [4]
- Noridian, a Medicare contractor, says a pre-licensed associate counselor cannot enroll, but can work as staff incident to a physician, PA, NP, CNS, CNM or clinical psychologist. Not incident to an LCSW, counselor or MFT. [10]
What supervision does behavioral health incident-to need?
General supervision, since January 1, 2023. The supervising practitioner must be reachable, for example by phone, but does not have to be in the office. Most other incident-to services still need direct supervision, which since 2026 can be given by live audio and video.
- The regulation says behavioral health services "can be furnished under general supervision" when staff provide them incident to a physician or other practitioner. CMS reads behavioral health as any service to diagnose, evaluate or treat a mental health disorder, including substance use disorder. [1][4]
- CMS added this rule in its 2023 physician fee schedule, naming LPCs and LMFTs as examples of the staff it covers. [5]
- For services that still need direct supervision, the supervisor's presence can be virtual through real-time audio and video, not audio only, permanently from January 1, 2026. CMS says this covers most incident-to services; certain surgical services are excluded. [1][7][8]
- Some sections of CMS's Benefit Policy Manual still describe only direct supervision, with the physician "physically present in the same office suite". Those sections predate the 2023 and 2026 changes to the regulation, which is the newer text. [2][1]
Does the supervising practitioner have to see the patient first?
Yes. CMS requires the practitioner to have personally performed an initial service and to stay actively involved in the course of treatment. Staff then provide the follow-on services.
- CMS's wording: incident-to services are "an integral part of the patient's normal treatment when the physician or other listed practitioner personally performed an initial service and remains actively involved in the course of treatment." [3]
- Several Medicare contractors, including Noridian, Palmetto and WPS, go further: incident-to does not apply to a new patient, or to an established patient with a new problem. Those visits are billed under the clinician who provides them. [9][11][12]
- We found those "new patient" and "new problem" words in contractor guidance only, not in CMS's own regulation, manual or booklets. Follow your own Medicare contractor's guidance.
How much does Medicare pay for incident-to services?
It depends on who supervises. Incident-to under a physician is paid at the physician rate; under a nurse practitioner, clinical nurse specialist or physician assistant it is paid at 85% of that rate.
| Supervising practitioner | Incident-to paid at |
|---|---|
| Physician | 100% of the physician fee schedule |
| Certified nurse-midwife | 100% of the physician fee schedule |
| Clinical psychologist | 100% of the fee schedule, if assignment is accepted |
| Nurse practitioner, clinical nurse specialist, physician assistant | 85% of the physician amount |
What changes in 2027?
From January 1, 2027, telehealth services billed incident-to need a new modifier, BC. It does not change payment. The 2027 fee schedule is still a proposal, and it does not change the behavioral health supervision rule.
- CMS's telehealth FAQ, updated October 8, 2026, says modifier BC marks "telehealth services that are furnished incident to a physician's or practitioner's professional service", is required from January 1, 2027, and has no payment effect. [8]
- CMS published the proposed 2027 physician fee schedule on July 14, 2026. As of October 23 no final rule has been published; we will update this guide when it is. [13]
- The in-person visit requirement for mental health telehealth is delayed to January 1, 2028. [8]
Do commercial insurers follow Medicare's incident-to rules?
No. Each insurer publishes its own policy, and several call it supervised or supervisory billing instead. Check the policy of every insurer you bill before an associate sees its members.
| Insurer | What it allows | Limits |
|---|---|---|
| Optum and UnitedHealthcare, commercial | Incident-to with the supervisor present on site; SA modifier for nurse practitioners and PAs | No general supervision exception for behavioral health |
| Optum, supervised billing for pre-licensed clinicians | Paid in California, Colorado, Hawaii, Iowa and Massachusetts; elsewhere only with Optum's prior approval; U5 modifier | Not for Medicare Advantage or evaluation and management visits |
| Optum, Medicare Advantage behavioral health | Incident-to under general supervision | Follows the stricter of state rules or general supervision |
| Aetna | Supervisory billing for license-eligible behavioral health clinicians; virtual supervision allowed | In network only; supervisor employed by the same group, listed as the rendering clinician |
| Cigna (Evernorth) | Billing for supervisees' services as state licensing allows | The credentialed provider is listed as the rendering provider |
| Anthem (New York, commercial) | Incident-to with SA modifier | Paid 15% below the supervising physician's rate |
| BCBS of Michigan (commercial), from March 1, 2027 | Eligible providers must bill under their own NPI | Incident-to with SA modifier paid at 80% |
Sources (20)
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Every source behind this guide, with the label we gave it and the date we read it.
Verified Official and primary sources
- [1]eCFR, 42 CFR 410.26, Services and supplies incident to a physician's professional service. The rules, general and virtual supervision, who staff can be. Read October 23, 2026.
- [2]CMS, Medicare Benefit Policy Manual, chapter 15. Older direct supervision text. Read October 23, 2026.
- [3]CMS, Incident to services and supplies. Initial service and active involvement; 85% under an NPP. Read October 23, 2026.
- [4]CMS, MLN1986542, Medicare and mental health coverage (March 2026). Who can bill, payment rates, behavioral health defined. Read October 23, 2026.
- [5]CMS, Calendar year 2023 physician fee schedule final rule fact sheet. The 2023 general supervision change. Read October 23, 2026.
- [6]CMS, Advanced practice registered nurses. NP, CNS and CNM incident-to payment. Read October 23, 2026.
- [7]Federal Register, CY 2026 physician fee schedule final rule. Permanent virtual direct supervision. Read October 23, 2026.
- [8]CMS, Telehealth FAQ (updated October 8, 2026). The BC modifier; virtual supervision scope; the 2028 in-person date. Read October 23, 2026.
- [9]Noridian (Medicare contractor), Incident to services, Jurisdiction E Part B. New patients and new problems. Read October 23, 2026.
- [10]Noridian (Medicare contractor), Associate counselors under incident to. Associates; who cannot supervise. Read October 23, 2026.
- [11]Palmetto GBA (Medicare contractor), Incident to: physician's professional services. New patients and new problems. Read October 23, 2026.
- [12]WPS (Medicare contractor), Incident to billing. New problems billed under the NPP. Read October 23, 2026.
- [13]CMS, Calendar year 2027 physician fee schedule proposed rule fact sheet. The 2027 proposal and its date. Read October 23, 2026.
- [14]Optum, Services incident-to a supervising health care provider, commercial. On-site supervision; SA modifier. Read October 23, 2026.
- [15]Optum, Outpatient services rendered under supervision, commercial. Supervised billing states, U5, exclusions. Read October 23, 2026.
- [16]Optum, Medicare incident to billing reimbursement policy. General supervision for Medicare Advantage. Read October 23, 2026.
- [17]Aetna, Provider education bulletin, Fall 2026. Supervisory billing for behavioral health. Read October 23, 2026.
- [18]Evernorth (Cigna), Behavioral health administrative guidelines (September 2026). Supervisee billing. Read October 23, 2026.
- [19]Anthem Blue Cross and Blue Shield, Incident to services and billing, professional (New York). The 15% reduction and SA modifier. Read October 23, 2026.
- [20]Blue Cross Blue Shield of Michigan, Changes are coming to incident-to billing policy (The Record, June 2026). The March 2027 change and 80% rate. Read October 23, 2026.