Incident-to Billing – Medicare Part B
What Is “Incident-to” Billing?
Incident-to billing is a reimbursement pathway for physicians to bill for services provided by nonphysician providers under their supervision, including pharmacists.
Incident-to billing is not exclusive to Medicare Part B reimbursement; however, this advocacy issue webpage is focused on incident-to physician billing in Medicare.
When certain requirements are met, incident-to billing allows physicians to bill Medicare for services provided by pharmacists, even though pharmacists are not currently recognized as providers or qualified health professionals (QHP) in Medicare Part B.
Policy Background & Opportunity
In the absence of federal recognition of pharmacist services, incident-to billing presents an opportunity for physicians and health systems to leverage to improve patient care, improve care team efficiency, and generate revenue.
Currently, restrictive limitations prevent physicians from billing incident-to for evaluation and management (E/M) services across all levels of complexity and medical decision-making when those services are provided by pharmacists.
The 2021 Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule final rule stated that pharmacist-provided services can only be billed under the lowest level E/M code, 99211, regardless of service complexity, because CMS does not recognize pharmacists as QHPs, who would be eligible to bill higher-level codes (99212–99215).
We support policies that allow physicians to bill for E/M codes across all levels of medical decision-making for established patients (99211–99215) and their telehealth equivalents (99441–99443) when services are furnished by a pharmacist under incident-to requirements.
(Source: 2026 Medicare Physician Fee Schedule) (view table as image)
Codes and Elements of Medical Decision Making |
|||||
|---|---|---|---|---|---|
| 99211 | 99212 | 99213 | 99214 | 99215 | |
| Reimbursement | $24.38 | $59.45 | $95.19 | $135.61 | $192.39 |
| Short Description | Established patient visit 5 min | Established patient visit 15 min | Established patient visit 30 min | Established patient visit 45 min | Established patient visit 60 min |
| Number & Complexity of Problems Addressed | N/A | Minimal | Low | Moderate | High |
| Amount/Complexity of Data Reviewed/Analyzed | N/A | Minimal or None | Limited | Moderate | Extensive |
| Risk of Complications and/or Morbidity/Mortality of Patient Management | N/A | Minimal | Low | Moderate (example: Prescription drug management) | High (example: Drug therapy requiring intensive monitoring for toxicity) |
Medicare Requirements for Incident-to Billing
- Must take place in a non-institutional setting (not hospital or SNF)
- Service must be part of the normal course of treatment for a diagnosis or illness
- Can only be done by non-physician practitioners (NPP) subsequent to initial encounter
- Care must occur under direct supervision
- Commonly rendered without charge or included in physician’s bill
- Physician must participate in and manage patient’s treatment
- Physician and NPP must be employed by the group entity billing for the service
Opportunities to Enhance Incident-to Billing
To make it financially feasible for care teams to leverage pharmacists in providing comprehensive medication management and chronic disease services—both in person and via telehealth—we support policies that allow physicians to bill for E/M codes across all levels of medical decision-making for established patients (99211–99215) and their telehealth equivalents (99441–99443) when services are furnished by a pharmacist under incident-to requirements.
Video Webinar on Pharmacist Incident-to Billing in Medicare
ASHP Incident-to News & Resources
- ASHP Pharmacist Billing/Coding for Patient Care Clinical Services Quick Reference pdf
- FAQ: Pharmacist Billing Using Evaluation and Management Codes and the “Incident-To” Rules for Non-Facility (Physician-Based) Ambulatory Clinics pdf
- Fast Facts for Ambulatory Care Billing: 2025 Physician Fee Schedule Update
- It’s Complicated: Financial and Billing Considerations for Managing Pharmacy and Medical Benefits
- Provider Status Means More Than Medicare Part B (June 20, 2025)
- ASHP and Partners Ask Dr. Oz to Remove Regulatory Barriers to Pharmacist Patient Care Services, Reimbursement (November 14, 2025)
Certificates
Enhance your clinical expertise with ASHP Professional CertificatesSM, which are tailored for practitioners and provides high-quality, practical education for pharmacists.
The Billing and Reimbursement for Patient Care Clinical Services Certificate is intended for pharmacists who are engaged in providing clinical services in a variety of practice settings, and others who are involved in billing for these services.
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