You would be distressed to find a medical practice that does not use Physician Assistants (PAs) and Nurse Practitioners (NPs), also considered as physician extenders or non-physician practitioners (NPPs).
Understanding how to properly bill and code for services provided by NPPs is crucial for executing a cost-effective and efficient medical practice. Regulations differ by insurance companies and states, therefore both the physician and the NPP’s must stay current with practice guidelines and ongoing changes.
NP and PA have increasingly become essential in most medical practices. NP’s are nurses who hold a Master’s Degree or Doctor of Nursing Practice (DNP). PAs are certified (PA-C), usually holding a Master’s Degree as well. There are several reasons that medical practices utilize these mid-level providers:
- Lower overhead costs
- Higher patient volumes
- Reduced Salary expenses (as compared to a physician)
- Reduced insurance and liability costs
Ways of NP and PA Providers Medicare Reimbursement
Now, look at various ways of billing for NPs and physician assistants (PAs). There are three essential types of reimbursement that Medicare provides for these non-physician providers (NPPs). Three reimbursement types provided by Medicare are:
Direct pay is when the NPP holds their Provider Identification Number (PIN). This reimburses the NPP at 85% of the billable physician rate. Each of your mid-level providers must get his/her own National Provider Identifier (NPI) and be credentialed with each payer to bill under his/her PIN, if possible, based on payer rules and regulations. However, many payers will not credential NPPs. Having the NPP credentialed allows practices to bill insurance companies directly when the “supervising physician” is either not on-site or has not provided any care or input into the patient’s plan of care.
“Incident to” billing is a way of billing outpatient services provided by a non-physician practitioner (NPP) provided in a physician’s office located in a separate office or an institution, or a patient’s home. With incident to billing, the physician bills and collects 100% of Medicare’s allowable reimbursement. This type of billing is used when an NPP sees a patient in which the physician has performed the initial service and has to commence a Plan of Care or treatment plan. There are specific rules for this type of billing, the physician must be on-site, in the suite, not just in the building, and provide direct supervision.
By filing an “Incident to” claim, the physician can collect 100% of the Medicare Physician Fee Schedule (MPFS) rather than 85% of the MPFS for care provided by a qualified NPP. New patients should be seen by the physician to set up the Plan of Care and this would be billed under the rendering physician. After the first visit, the NPP can provide follow-up care based on the Plan of Care, billing for direct care as “Incident to”. If adjustments are made to the plan of care such as medication changes, then the physician should see the patient face to face to regulate the original plan of care, or else, the visit may not entitle to “Incident to” billing.
“Incident-to” billing was developed by Medicare and not all commercial insurance carriers follow Medicare guidelines, thus knowing payer regulations regarding “Incident-to” billing is imperative before providing patient care.
“A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam, or medical decision-making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer.”
Billing for shared/split services allows the practice to bill under the qualified physician versus the NPP at their lower reimbursement rate. Since the criteria are met, billing for shared/split services allows for that extra 15% reimbursement.
Documentation is important in this type of billing. Each practitioner must completely document the care they provided to support reimbursement under the split/share guidelines allowing both parties to bill for care.
According to the Centers for Medicare and Medicaid Services (CMS), shared/split visits are applicable for services provided in the following settings:
- Hospital inpatient or outpatient
- Hospital observation
- Hospital discharge
- Emergency department
- Office or clinic (when “incident-to” requirements are met)
Shared/split visits are not allowed:
- For consultation services
- For critical care services
- For procedures
- In a skilled nursing facility or nursing facility setting
- In a patient’s home or domiciliary site
With shifts in healthcare spending, patient care, reimbursement, and physician shortages, the need for Nurse Practitioners and Physician Assistants is greater than ever. A real understanding of the billing and reimbursement guidelines for individual payers is mandatory. And charting and documentation requirements must be met.
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