Incident to Physician Participation Rules

While Centers for Medicare & Medicaid Services does not explicitly define a strict “12-month rule,” its guidance does require that the physician’s involvement reflect ongoing, active participation in the patient’s course of treatment.

That said, legal and compliance experts consistently caution that if a physician has not personally seen a patient within 12–24 months, billing subsequent non-physician practitioner (NPP) visits as “incident to” may present elevated audit risk. Terry breaks down the lack of clear regulatory thresholds and outlines practical steps to help protect your practice if an audit inquiry occurs.

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