Incident-to Billing for Nurse Practitioners: 2026 CMS Guidelines
Quick answer
Incident-to billing lets a nurse practitioner's office visit be billed under the supervising physician's NPI and reimbursed at 100% of the Medicare Physician Fee Schedule rate, instead of the 85% rate Medicare pays when the NP bills under their own NPI. It only applies to established patients with an already-established plan of care, and the supervising physician has to be immediately available - physically present in the office suite, or, since a CY 2026 CMS rule change, available through real-time audio/video technology - while the NP furnishes the service. New patients, new problems, and any change to the plan of care must be billed under the NP's own NPI at 85%.
The 5 CMS requirements for incident-to billing
All five have to be true for the same encounter. If even one isn't met, the visit has to be billed under the NP's own NPI at 85% of the Medicare Physician Fee Schedule rate instead of incident-to at 100%.
Established patient
The visit can't be the patient's first encounter for the condition being treated. Medicare's incident-to rule exists to cover follow-up care within an existing course of treatment - not new patients or new problems, which always have to be billed under the NP's own NPI.
Established plan of care
A physician (or the NP, billing independently for that encounter) must have already evaluated the problem and set the treatment plan. The incident-to visit has to follow that plan, not modify it - if the NP changes the diagnosis or the plan of care during the visit, incident-to billing no longer applies for that encounter.
Physician immediately available (direct supervision)
The supervising physician doesn't need to be in the exam room, but has to be immediately available to assist. Historically that meant physically present in the office suite. Under the CY 2026 Medicare Physician Fee Schedule Final Rule, CMS permanently expanded this to also allow real-time, two-way audio/video technology - audio-only doesn't qualify - for most incident-to services (a small set of procedures with 010/090 global-surgery indicators are excluded).
Ongoing physician involvement
The physician has to remain actively involved in the patient's course of treatment - periodic involvement in the case, not a single visit years earlier with no subsequent role.
State scope-of-practice law must allow it
Incident-to is a federal Medicare billing rule, not a grant of clinical authority. The NP still has to be authorized under their state's nurse practice act to furnish the service in the first place - incident-to billing can't be used to work around a state scope-of-practice restriction.
Incident-to billing vs. billing under your own NPI
This is the real decision most NPs are weighing: take the lower, unconditional 85% rate in exchange for full autonomy, or meet incident-to's conditions for the 100% rate. Which one makes sense in practice tends to track your state's practice-authority tier.
Incident-to billing
Reimbursed at 100% of the Medicare Physician Fee Schedule, billed under the supervising physician's NPI. Requires an established patient, an established plan of care, and an immediately available supervising physician for every qualifying visit. New patients and new problems never qualify. Documentation has to clearly support each requirement, since incident-to claims draw more audit scrutiny than independently billed ones.
Most common in: reduced and restricted-practice states, where a collaborating or supervising physician is frequently already on-site for scope-of-practice reasons.
Independent billing (NP's own NPI)
Reimbursed at 85% of the Medicare Physician Fee Schedule, no exceptions, but with no incident-to conditions to satisfy - no established-patient requirement, no on-site physician requirement for Medicare billing purposes, and no restriction on new patients or new problems. State scope-of-practice law still governs what the NP is authorized to do independently.
Most common in: full-practice-authority states, where NPs often don't have a physician on-site at all and value the autonomy over the 15-point reimbursement gap.
See the full practice-authority breakdown by tier on the NP private-practice guide and the state-by-state scope tool on the NP scope-of-practice page.
What actually changed for 2026
The established-patient, established-plan-of-care, and ongoing-physician- involvement requirements are unchanged. The one requirement that moved is direct supervision: the Calendar Year 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F) permanently adopted a definition of direct supervision that lets the supervising physician be "immediately available" through real-time audio and visual interactive telecommunications, instead of requiring physical presence in the office suite. Audio-only doesn't satisfy it, and a small set of services with 010/090 global-surgery indicators are excluded. CMS had permitted this as a temporary COVID-era flexibility since 2020 and extended it annually through 2025; the 2026 final rule made it permanent.
In practical terms: a physically-present, in-suite physician still satisfies direct supervision exactly as before. What's new for 2026 is that a real-time audio/video connection is now a permanent, valid alternative - not that the underlying requirement to be available disappeared.
Frequently asked questions
What is incident-to billing for nurse practitioners?
Incident-to billing lets a nurse practitioner's office visit be billed under the supervising physician's NPI and reimbursed at 100% of the Medicare Physician Fee Schedule rate, instead of the 85% rate Medicare pays when the NP bills under their own NPI. It only applies to established patients with an already-established plan of care, and the supervising physician has to be immediately available - physically present in the office suite, or, since a CY 2026 CMS rule change, available through real-time audio/video technology - while the NP furnishes the service. New patients, new problems, and any change to the plan of care must be billed under the NP's own NPI at 85%.
What are the incident-to billing requirements?
Five conditions have to hold at the same time: the patient is established (not a new patient or new problem), the plan of care is already established and isn't being changed at this visit, the supervising physician is immediately available under CMS's direct-supervision standard, the physician remains actively involved in the patient's ongoing care, and the NP is authorized under state law to furnish the service. Miss any one of them and the visit has to be billed under the NP's own NPI at 85% instead.
What changed in incident-to billing rules for 2026?
The core eligibility requirements - established patient, established plan of care, ongoing physician involvement, state scope-of-practice authority - are unchanged for 2026. What changed is how "direct supervision" can be satisfied: the Calendar Year 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F) permanently adopted a definition of direct supervision that allows the supervising physician to be immediately available through real-time audio/video technology instead of being physically present in the office suite (audio-only doesn't qualify, and a small set of services with 010/090 global-surgery indicators are excluded). CMS had allowed this virtual-supervision option as a temporary flexibility since 2020; the 2026 final rule made it permanent. See the Sources section below for the CMS fact sheet.
Can a new nurse practitioner patient be billed incident-to?
No. Incident-to billing requires an established patient with an established plan of care. A new patient visit, or an existing patient presenting with a new problem, has to be billed under the NP's own NPI at 85% of the Medicare Physician Fee Schedule rate - it can't be billed incident-to even if a physician is on-site and available.
Does incident-to billing apply the same way in full-practice-authority states?
Incident-to is a federal Medicare billing rule and applies the same way regardless of state practice-authority tier. What differs is how often it's used. In full-practice-authority states, NPs frequently don't have a physician on-site at all, so most visits are billed independently under the NP's own NPI at 85% in exchange for full autonomy. In reduced or restricted-practice states, a collaborating or supervising physician is often already on-site for scope-of-practice reasons - which makes it easier to also meet incident-to's physician-availability requirement and bill some established-patient visits at the 100% rate.
What happens if incident-to billing requirements aren't met?
Billing a visit as incident-to when it doesn't meet all the requirements is an improper claim, regardless of intent. Medicare can deny the claim, require repayment, and - if a pattern of noncompliant incident-to billing shows up in an audit - escalate to a broader compliance review. Practices typically build a documentation checklist into the chart (who saw the patient first, what the plan of care was, who was supervising and how) specifically so an incident-to claim can be defended on audit.
Do incident-to rules apply to telehealth visits?
The 2026 direct-supervision change addresses how the supervising physician can be available (in person or by real-time audio/video) - it doesn't change where the NP's visit with the patient itself has to happen. Incident-to services are still tied to office-based, physician-directed care, and Medicare's telehealth billing rules have their own separate requirements. This is an area where the rules keep moving - confirm current telehealth-specific requirements with CMS or your billing compliance staff before billing a virtual visit as incident-to.
This page is general information, not billing, compliance, or legal advice. Incident-to rules involve real audit risk and change over time - verify current requirements with CMS, your Medicare Administrative Contractor, and your practice's billing/compliance staff before relying on this information to bill a claim.
Applying these rules visit-by-visit is the hard part
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