How to Bill for Nurse Practitioners and Physician Assistants
You would be hard pressed to find a medical practice that does not use Physician Assistants (PAs) and Nurse Practitioners (NPs), also referred to as physician extenders or non-physician practitioners (NPPs).
Understanding how to properly bill and code for services provided by NPPs is imperative to running a cost-effective and efficient medical practice. Regulations vary by insurance companies and states, so both the physician and the NPP’s must stay current with practice guidelines and ongoing changes.
Nurse Practitioners and Physician Assistants have increasingly become a staple in most medical practices. NPs 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 a number of reasons that medical practices utilize these mid-level providers:
- Reduced Salary expenses (as compared to a physician)
- Lower overhead costs
- Higher patient volumes
- Reduced insurance and liability costs
There are 3 basic types of reimbursement that Medicare provides for these non-physician providers (NPPs).
Direct Pay
Direct pay is when the NPP holds their own Provider Identification Number (PIN). This reimburses the NPP (or practice) at 85% of the billable physician rate. It is very important that each of your mid-level providers receives his/her own National Provider Identifier (NPI) and be credentialed with each payer to bill under his/her PIN number, 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 patient’s plan of care.
“Incident to”
“Incident to” billing is a way of billing outpatient services rendered in a physician’s office located in a separate office or in an institution, or in a patient’s home provided by a non-physician practitioner (NPP). 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 initiated 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 provides direct supervision (the rules for home visits varies).
By filing a claim “Incident to”, the physician can collect 100% of the Medicare Physician Fee Schedule (MPFS) instead of 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 initial 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 in order to adjust the original plan of care, otherwise, the visit may not qualify for “Incident to” billing.
“Incident to” billing was developed by Medicare and not all commercial insurance carriers follow Medicare guidelines, therefore knowing payer regulations regarding “Incident-to” billing is imperative prior to providing patient care.
Split/Shared Expenses
Billing for shared/split services allows the practice to bill under the qualified physician versus the NPP at their lower reimbursement rate. As long as the criteria are met, billing for shared/split services allows for that extra 15% reimbursement.
Documentation is paramount in this type of billing. Each practitioner must thoroughly document the care they provided to substantiate 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 rendered in the following settings:
- Hospital inpatient or outpatient
- Emergency department
- Hospital observation
- Hospital discharge
- Office or clinic (when “incident-to” requirement are met)
Shared/split visits are not allowed:
- In a skilled nursing facility or nursing facility setting
- For consultation services
- For critical care services
- For procedures
- In a patient’s home or domiciliary site
Conclusion
With shifts in healthcare spending, patient care, and reimbursement, and physician shortages, the need for Nurse Practitioners and Physician Assistants is greater than ever. A Proper understanding of the billing and reimbursement guidelines for individual payers is necessary. Charting and documentation requirements must be met.
Does your medical practice use NPs or Pas? Are you billing “Incident to”? Let me know in the comments below.
Does a PA get the same amount of copay as a specialist?
Our practice consisted of only one doctor (also owner of practice). He hired an NP to help with patients. We have slowly gotten her credentialed with several payers. Would we be billing claim with the doctor as billing provider while listing NP’s npi as rendering provide. We are in Texas
I am unable to get a new patient PCP without an initial consult as a Medicate Advantage recipient. Do I pay for that? Of the PCPs doctors name is on the card does that make a difference in Billing if I have never gone to that PCP?
A ssn background check that only looks for records based on the applicant’s name and date of birth can leave out information if that person used to be known by a different name. If the person committed a crime while using a maiden name and the background check only searches for records under the person’s married name, the record of the criminal conviction could be overlooked.
What happened as far as RVU reimbursement for the visit if a mid- level see a patient, creates the note and after signing the supervisor physician request co-sign.
The RVU is split between them or the mid level receives the credit?
What documentation is required by the physician in the office note to meet incident-to requirements?
1. In NC can the office allow an NP to see a new patient, and bill under the CPA/group/supervising Dr.’s NPI? or should the NP only bill under her NPI, since this is a new patient?
2. Can the outpatient facility bill a Revenue Code 511 along with a new patient code 99204, when only the E/M was done and no procedure occurred?
We have hired a Nurse Practitioner for our office to help the physician. When billing, are we able to bill “incident to” if the patient see the NP first then the Doctor goes in to see patient? The NP is spending more than 50% of time with the patient. Whose npi goes where and is there any modifier used?
WE ARE A MEDICAL PRACTICE AND WE HAVE A NURSE PRACTITIONER WORKING IN OUR PRATICE, SHE SIGNED OVER ALL HER BENEFITS TO THE DOSTOR IN THE PRACTICE. I KNOW WE BILL UNDER THE GROUP NPI AND TAX ID BUT THE QUESTION I HAVE IS FOR THE DOCTOR DOING THE SERVICE DO WE USE THE NURSE PRACTITIONERS NPI OR DO WE USE THE DOCTORS NPI THAT SHE REASSIGNED ALL HER BENEFITS TO?
Hi I am an NPP in NY state and board certified for the last 5 years unfortunately I didn’t get my CEU’s to the ANCC board where my certification is through so as of currently I am working on it but wanted to know how I would bill or have my office bill my visits with patients going forward until I am re-certified? I do gave a collaborator even though I do NOT need one so not sure if this matters? Any help would be appreciated thanks!
Best,
Carrie Glans, PMHNP
Can you submit billing charges to insurance, when a PA sees the pt and signs the chart. But the chart is not signed by an MD/supervising physician?
I have same question.
also, when we bill Medicare when PA sees the Pt and we bill under supervising provider (MD) dose chart has to be cosigned by MD? same with PPO HMO
we always bill under supervising md in the office, but the chart needs to be cosigned by the MD?
Manny, can a Pharmacist, working under a Collaborative Practice Agreement with a hospitalist MD, inject medications in a hospital based Pharmacy Medical Management Clinic, bill, AND the clinic get reimbursed? Would the Clinic receive Incident To reimbursement? The hospitalist is in the building, but maybe not in the Medical Management Clinic continuously.
The Medical Management Clinic is currently billing Med Therapy Mgmt using 99605, Transition of Care Mgmt using 99496 or 99495, Chronic Care Mgmt 99490, and Incident To 99211.
I work for a behavioral health facility and we bill services for APRNs that have a Family Nurse Practitioner Certifications, they are credentialed with Medicare but recently we have been having issues with getting them credentialed with the Advantage plans. They claim that the provider has to have a Psychiatric-Mental Health certification. Are you aware of any policy changes? Medicare is still adding these providers to the Medicare network.
My daughter is a new NP working for a small derm office in DE.
She has concern because she is the only one seeing the a Medicare patient. Not the doctor but they are charging the Medicare as if the doctor saw the patient. This happens often and many times she is left in an empty practice late in the day to see patients all by herself.
The owner doctor charges all these patients at his full rate. Not the NP rate. Can she ne held criminal liable in any way ?
I WORK FOR FNP-C BILLING. I get alot of denials to pay due to incidental to procedure. Can you assist in explaining this. im confused?
When a patient with Blue Shield sees a NP am I always supposed to document the NP as the rendering provider?
Who are you billing under?
We are billing under the group.
WHY DOES AN OFFICE ONLY CHARGE 20% IF THERE IS ONLY A PA IN THE OFFICE FOR MEDICAL CLAIMS?
20% is the percentage you pay once the deductible is met. So if they charged that it’s considered your coinsurance and it will apply until your OOP is met. Are you concerned that you were seen by a PA they are qualified professionals trained to see patients as if a Dr would
My insurance is requiring me to pay for a specialist but I use a pa under my primary care provider. Since when is she a specialist?
A lot of the times it’s based off your diagnosis. We have a husband and wife who come to our office. See the same provider , one pays the medical co pay of $25 and the other pays the specialty co pay of $60. One Has ADD, the other depression.
Hello. I am a PA-C working in an Urgent Care position. Just recently billing has told me that I need to bill differently for ‘New’ vs ‘Established’ visit. I had always considered a patient new if they had not been seen in our ER or Urgent Care in the past three years. Now I am told that according to medicare rules that if the patient was seen by any NP or PAC in our clinic, regardless of speciality, it would be considered established encounter. This makes no sense.
Hi Patti/
Did you ever hear back?
I was just told the same thing. I’m a Nurse Practitioner in a busy orthopedic office. See patients independently and bill New if they are new to the practice (or haven’t been seen in 3 years).
I was just told that if the patient sees ANY provider under our hospital umbrella, including their PCP, I cannot bill new patient-only established. My salary is RVU based and I’m beyond surprised about this.
I was billing new patients at a nearby practice for 15 years and this is the first I’ve heard of this!
My employer wants to know if there is a difference in the reimbursement rate for ARNP’s is at a different percentage than the PA’s are reimbursed?
Medicare fee schedule allows 10% for ARNPS but we would like to know the percentage of payment for a PA.
Thanks
It has come to our attention that UHC Commercial, we were not in contract with them with our Mid-Level (Nurse Practitioner) so we starting to see a lot of claims that have been denied.
This is my question can we bill these under the Provider (Supervisor Physician) and send back corrected claims?
We have a FNP that is asking if she can see all Patients (UHC Commercial) and just bill under the Provider?
I’m an NP provider in a solo psychiatry & substance use practice. I have a collaborating physician in another part of the state who is available on an as-needed basis, which was twice in 5 years. I’m credentialed by Medicare, Medicaid, & all the insurance companies that are billed for my services.
I provide med management (E& M 99213 to 99215,) & psychotherapy (90833 or 90836).
Claims are being denied due to the 90833/36 code.
There is a practice NPI number, but claims are submitted under my NPI number,
I use the modifier HF for substance abuse programs, & 95 for telehealth if applicable.
My billing manager was told to add the SA modifier in order to be paid for all services. Looking at the definition of the SA modifier it states “code used by the physician…” Reading various sources it seems I should be using SA for any services I’m billing. I’m not sure what to do.
Manny could you shed some light on this, please. TY
Hi Manny. Can an NPP of an orthopedic physician provide an initial PT evaluation (97161) to a patient, assuming it is after the physician has seen the patient? If so does this require any additional documentation other than the GP modifier added to the 97161? Lastly, can this service be provided remotely or does it have to be in person
I have a question about the Q6 modifier. We are a single provider practice with a PA-C as our provider. When he goes on vacation, if I get a locum how would I bill that out? I’ve been told that Q6 can only be used for an MD, so how do you code if a fill in comes in for an NP or PA?
Hello! I’m wanting to see if I can get some clarification to give to my provider, regarding Medicare Incident To rules. He feels that he is to be the supervising physician for all patient’s since he’s the MD/owner and is in the office for supervision, if needed. He feels that even if the ARNP changes a medication, Discusses a new Diagnosis or is New to the practice that he still is to be the supervising physician. I have articles from AAPC, Medicare’s processing manual, Chapter 60.1 that support me saying “no to Incident To” to these types of situations with the ARNP.
He says that there was an update to Incident To rules because of Covid (he’s referring to the Direct Supervision by Interactive Telecommunications Technology interim final policy revising the definition of direct supervision to include virtual presence of the supervising physician using interactive audio/video real-time communications technology) that is set to expire 12/31/21. His interpretation is that as long as he can be contacted via telecommunication that we can still count this toward his direct supervision and will be able to bill Incident To. Does this new direct supervision interim final policy encompass all types of visits or just Covid related visits? This is what I need clarification on.
i also have the same question
it would be great if we get some clarification
so even PA sees he patient and supervising provider is not present at the site but available through phone can we bill under supervising provider????
I see a PA as my PCP rather than the Dr. she works under, BCBS is considering the PA a specialist, making co-pay $30, whereas, they tell me if I saw the medical Dr. in the same office they would consider it a PCP and only $10 co-pay. This makes no sense to me at all. Does that seem right?
It is possible that particular PA is a specialist (those do exist.) Or it’s also possible that BCBS has your PA listed incorrectly–I work for an ACO and I can’t tell you how many things BCBS has screwed up. Or the incorrect taxonomy is associated with the PA’s NPI. The best thing to do is check the PA’s NPI and see what, if any, specialty is listed. If something doesn’t make sense, the office will need to call BCBS and get it fixed. Which might take a while.
If the physician reads and signs the note that the nurse practitioner has documented after seeing the patient because the position has signed the note are we allowed to Bill under the physician or do we have to bill under the nurse practitioner
Hi Manny,
Great article. Would you know if a nurse practitioner makes a phone check in for a patient that was seen initially by a physician, how should you bill: physician or NP?
Hi Manny,
How can a PA bill for psychotherapy? BCBS changed their policy in July 2019 and is not paying out 90833 anymore for the PA. Other insurance companies pay this code to the PA. Is there a code that is like psychotherapy but won’t fall under the behavioral health side of things?
By engaging with the sourcing group the design team can integrate real market data to rationalize the design under development with the current state of the supply base.
My question pertains to a Physician’s Assistant assisting surgeon in OR. Is the modifier AS Active and would we get reimbursement for the PA? 80 is for another Surgeon, 81 Seems like it pertains to another surgeon participating in only part of surgery. What is the correct code for submitting claim and getting reimbursement for PA assisting in Surgery?
Hello, I have been reviewing Medicare Guidelines and my understanding is that if a patient shows up to their appointment ready to see their PCP, but offered/told they will be seeing the Nurse Practicioner, insurance companies should NOT be processing the NP as a specialist visit. Am I correct? The patient is paying their PCP copay, then being billed the difference between that and their Specialist copay, and we are out the money. Anyone else experiencing this?
Hi Lanyna —
If I understand your question correctly, as far as I know, what drives the copay is how the practice is credentialed with the insurance. Are they a PCP or are they a Specialty practice? Whether an MD, OD, NP, PA, LCSW, etc sees the patient is irrelevant. It’s the group taxonomy that drives the copay. Sounds like the front desk is collecting the wrong copay. It’s expensive to bill for an extra $10 or so.
We have this issue also. We have several commercial insurance’s that state CRNP’s are specialists even though they work in a primary care setting and are billed under primary care. Therefore, the insurance will apply a specialist copay to the claim. Patient’s get upset about this and think that we are billing the ins incorrectly, when we are not. We have asked insurance companies to reconsider their pymts due to this fact but they will not budge.
I am actually on this website looking for answers to the same issue. No PCP in the office to see, so you have to see the NP. I am also being charged for the NP as a specialist when my PCP office visit charge is lower ($5 vs $35 for a specialist). It appears the patient will be left holding the bag at this point via way of a loop hole for NP billing. This needs to be addressed and corrected immediately! Healthcare is expensive enough, and when you choose a plan you expect to pay the charges indicated when accepting the terms of the plan; not an arbitrary charge allowed after the fact that you weren’t aware of in the first place. This could lead to even more people choosing to put their healthcare on hold unless the PCP is available to see patients; along with appeals for charges.
I saw patient and find out patient was charged as new patient for $204 . I am a nurse practitioner and the Code was 99203. Insurance blue shield, blue cross. Insurance just paid $15. It seems the charge for specialist office. How do I know the amount is right?
I am assuming you are talking about the amount of the copay. Typically if you work for a specialist you collect a specialist copay, for a PCP, the PCP copay, which is usually lower.
But sometimes the insurance just plain gets it wrong. Sounds this is an isolated claim. Send in a reconsideration if you choose.
Hopefully, I understood corretly.
I’m an NP provider in a solo psychiatry & substance use practice. I have a collaborating physician in another part of the state who is available on an as-needed basis, which was twice in 5 years. I provide med management & psychotherapy. I use E& M 99213 to 99215, and 90833 or 90836.
Claims are being denied due to the 90833/36 code.
I bill under my NPI number, but there is also a practice NPI number.
I use the modifier HF for substance abuse program, & 95 for telehealth if applicable.
My billing manager was told to add the SA modifier in order to be paid for all services. Looking at the definition of the SA modifier it states “code used by the physician…” Reading various sources it seems I should be using SA for any services I’m billing. I’m not sure what to do. Manny could you shed some light on this, please. TY
Thank you for posts. I have a question. I will be preforming Medicare Annual Wellness Visits ( G0438-39) in a doctor’s office. He will be in the office, but he won’t see those patients. Is it better to bill incident to or simply reassign my billing to him (I will be rendering, but he will be billing)?
Second question: How does Medicare look at the doctor splinting the fee with APP?
I would suggest billing as yourself and I am not crazy about the words, “fee-splitting.”
I know this doesn’t help much.
Mr Oliverez,
Please explain to me how this is acceptable/legal for the patient and insurance, Michigan BCBS reimburses a nurse practitioner who bills under a physician NPI, PIN, and tax ID numbers the same rate as physician. I have never seen the doctor who owns facility there is a NP at the premises the actual doctor who owns multiple locations works out of a different office. I see why it is done, “greed” however there is no doctor in house over seeing the NP’s work let alone patient has no excess to a physician. I don’t believe anyone should be reimbursed a fee of seeing physician when this is not so or even available to a patient. Please help me correct this.
Here is some information on NP billing from Medicare that may help answer your questions.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Medicare-Information-for-APRNs-AAs-PAs-Booklet-ICN-901623.pdf
I am billing in Florida. I was told very adamantly by a NP working with the office that they are now reimbursed at the rate for commercial and Medicare insurances. I don’t believe this to be true. Can you shed any light on this topic?
Hello Mr. Oliverez. We use PAs and NPs in our medical practice. Through Caresource, for years, we have distinguished the mid levels by use of a SA modifier. Within the last few months, we started getting denials for the PAs stating OA4 – The procedure code is inconsistent with the modifier used or a required modifier is missing. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. I called Caresource and insisted that this is the correct modifier and that we have used it for years. I was told by the CSR that it was not. I pulled the reimbursement policy for Caresource Medicaid Ohio and researched the modifiers. I found an alternate modifier which seemed to be the only other one that could be used and was specific to PAs (UD modifier). I sent through a couple of tests and found that it would pay. I didn’t really pay attention to the amount paid, only that it paid. We began using UD instead of SA for PA-Cs. Yesterday, I received an ERA which had 67 payment adjustments. I compared the PA to the NP and found that the NPs were actually paying at a higher rate than the NP (our PAs have much more education and training than NPs so I couldn’t logically wrap my head around the fact that an NP would pay more than PA. I called Caresource and didn’t get anywhere. They couldn’t tell my why the denial all of a sudden and if I was eveni using the right one. If possible, please advise as to where I can go from here. We have a fairly large practice with 4 PAs and 3 NPs so the impact of these adjustments will end up being quite large should I need to resubmit corrected claims. Thank you for your time.
Hi Lora,
I’m curious whether you’ve continued to have success w/ the UD modifier for NP’s? We’re running into that same issue of payment being denied for our NP billing under her own NPI. Any info you have would be appreciated!
Manny,
If a PA or NPP sees the patient but the physician is in the office, can I bill the physician as the rendering, and billable provider or is this considered fraud?
This article concerning the aspects of medical billing was very informative and ensured a complete understanding within me. As we possess a specialized website in relation to medical billing benefits, this article was very much essential for the development of my perspective of medical billing. If you want more details associated with medical billing.
Manny, when billing E&M and fracture care in ER does the MD have to documentation that he participated in the fracture care to bill under MD or does this have to be billed by NP who performed procedure for BCBS?
Can the MD bill for the Home Health Certification if he is the supervising for the NP who performed and completed the assessment/order? He has never seen the patient.
Never saw my physician on my office visit only nurse practitioner. EOB has physician name as provider. Dr. Office wants me to pay copay as if I saw the physician. What should I do?
Hi Don —
Pay the copay.
Some insurance companies do not credential nurse practitioners so they are allowed to bill under the physician.
I need help with E visits and billing for Sleep workup. I am not the PCP for these patients .
Unfortunately, Marla, I don’t bill sleep studies so I can’t help you with this but maybe someone else will have an answer for you.
How is it suppose to show on the claim for an incident to claim. When the PA-C sees a patient for medication management follow up. Does it just file out under the M.D. and his NPI or does the PA-C and his NPI have to be listed on the claim?
Solo Nurse Practitioner group, has own NPI group/individual NPI/TAXID/Texas PTAN.
NP, sees own patient
Billing provider:NP details
Rendering provider:NP details
On claim should supervising provider name show, even though its NP practice and MD is within 50 mile radius and MD does not own the practice. MD is only delegated provider.?
Any input helps please.
Does np and pa bill and receive same amount of payment as a physician in Michigan? Per Medicare and BCBS. The np I see is in solo practice physician that owns this practice is seeing patients in an office in different location. Per eob from Medicare and BCBS there does not seem to be a discount, is this legal?
I am a Psychiatrist NP, I have a private practice, Can I bill for office visit separately from ICD codes
Please clarify: Can a NP see an established patient in the office without the ordering doctor being in the building, however one of the other doctors in the practice is physically in the building, can the NP bill incident-to under the ordering doctor or does she have to bill incident-to under the doctor that is physically in the building?
We are working with a private insurance payer who doesn’t credential NPs and requires billing under the supervising provider. Is this compliant? Does it matter that the patient is not a Medicare patient?
Need help with this a PA is working under supervision of an MD if the the supervising MD
is billing for services the PA performed is there any modifier to be used for those EM codes to clarify that this patient was seen by PA? Please help me . Thank you
a PA is working under supervision of an MD if the the supervising MD
is billing for services the PA performed is there any modifier to be used for those EM codes to clarify that this patient was seen by PA?
I too, would like to know if an NP or PA can do the history on a new office patient or consultation with me, a physician, doing a directed history, physical exam, assessment and plan. If I am the only one charting and signing off on the chart, can I bill for my services as a new patient or office consultation cannot technically be shared. Also, can I bill incident to for follow up visits assuming that I had previously seen the patient and a diagnosis and a treatment plan had been outlined by me? I know that I would have to be physically in and available within the same suite as the mid level provider. I realize that I could not bill incident to if the patient were to present with a new problem.
Per CMS new patient services must be personally performed by a physician with the exception of history obtained by ancillary staff.
If a nurse practitioner sees a new patient in the office to obtain the history and perform an examination but then passes the encounter off to a physician who conducts a pertinent exam (one body system/part) and determine the A/P, does this suffice as “personally performed?”
It is essentially a split/shared service in an outpatient office that is being performed. Does the physician need to do the entire E/M themselves or can the elements be divided between the physician and NP?
When billing incident to, you state any change in the plan of care would not qualify under this unless the physician directly sees and agrees with new plan. Would this be consistent with any new medication prescribed, even if diagnosis is already present just not improved. Ex: Nausea in chemo patient and zofran not working, therefore compazine given. Would the physician need to see this patient and agree to plan to bill incident to.
a PA is working under supervision of an MD if the the supervising MD
is billing for services the PA performed is there any modifier to be used for those EM codes to clarify that this patient was seen by PA?
I need some guidance on filling for a NP who has NO numbers yet, straight out of school. Am I aloud to bill regular insurance under the Physician he is employed under and not have him see Medicare/Medicaid until I get his NPI/Medicare/Medicaid #’s?
Is reimbursement the same for a PA as an NP?
Can a GA Physician Assistant bill incident to a nurse. The nurse is given allergy shots and the physician assistant is the only provider on site, supervising provider is on vacation. Where can I find the guidelines for this. I say we can’t bill, but the PA says we can. Also if the physician assistant is the only one in the clinic for a BCBS patient do we bill under the supervising physician.
I have a medical doctor who would like to hire a NP to do her hospital rounds. The NP has a NPI # and a Medicare PTAN #. Does the M.D. have to be on the premises in order to bill Medicare? The M.D. I supposed would be the “supervising physician”? This M.D. will be either NOT on site or has not provided any care or input into patient’s plan of care.
If you have any Medicare billing tips, I would greatly appreciate it.
Hi Michelle — No the MD does not have to be on site. The NP can bill under the practice with their NPI and receive 85% of the allowable for the service. The MD can be the supervising physician. Check with your local Medicare carrier for their specific rules.
Great article. We currently use NPP’s in our practice. I have a question: when our NPP’s see a patient for a new problem, we bill under their NPI. If the physician sees this patient for follow up care and sets his own plan of care, and then has the NPP follow up, will this then be considered incident to? I am assuming the doctor must see the patient face to face to establish his plan of care.
Thanks
Lee A
Thanks for sharing. I still haven’t really covered this issue, but I guess it is the high time to take it into serious consideration.I currently work with an assistant and our billing system is far from perfect…
Coding and billing is a big part of our curriculum. We will have to consider this information.
Manny!
Great article with perfect timing as we are just about ready to hire a part time PA. Could you also comment on the expected delay of reimbursement secondary to the CCM certification requirement under the hiring doctors. NPI number? It’s a confusing issue. As I understand it, there is no reimbursement from Medicare or Medicaid while the new hire has their NPI number linked to the Doctor’s NPI number. This can take up to 120 days. That means no reimbursement for services rendered for 3-4 months! So if you’re hiring you should have enough saved up to pay a salary the first 3-4 months.
Thanks.
A new hire provider has to be credentialed through Medicare and Medicaid and as you understand, it can take several months. Since the provider is not credentialed, you are correct that there will be no reimbursement for services.
I have heard of practices doing one of two things:
1. The new provider does not see Medicare or Medicaid patients or
2. The new provider sees Medicare patients but does not bill Medicare or Medicaid.
Now the best thing is to start the credentialing process months before the provider comes on board so that the new provider is ready to go on day one. That may not always be possible.
What I have heard usually happens is the provider does see Medicare and Medicaid patients, following all the rules and regulations, but the claims are put on hold.
When the practice finally gets the Welcome letter stating that the new provider has been credentialed there is an effective date for the provider. This effective date is usually several weeks prior to getting the letter. It is then possible to release all the claims as of that effective date for payment.
There are of course claims prior to the effective date have to be written off.
Does an NP need to be credentialed with commercial carriers (BC,BS, Aetna, etc) for inpatient Critical Care billing? They are not going to see the patient in an office setting. Almost all of the Critical Care physicians are “out-of-network” Can an NP be “out-of-network” as well?
Once enrolled in the Medicare program as a provider, the responsibility of understanding and abiding by the rules and regulations falls on your shoulders.