Coding and Billing for NP and PA Providers in Your Medical Practice
Health Insurance Companies Process 1 in 5 Claims Wrong.

Coding and Billing for NP and PA Providers in Your Practice

How to Bill for Nurse Practitioners and Physician Assistants

You would be hard pressed to find a medical practice in 2017 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

Split/shared expenses:  “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.   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. 

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32 thoughts on “Coding and Billing for NP and PA Providers in Your Medical Practice”

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    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.

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    Frankie Grandberry

    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?

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    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.

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    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?

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    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.

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    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?

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    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?

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    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.

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    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?

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    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?

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    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?

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    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

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    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?

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    Jay Kozlowski

    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.

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    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?

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    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.

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    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?

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    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?

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    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.

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    Michelle Costarella

    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.

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      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.

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    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

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    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…

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    Rodney Muhammad

    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.

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      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.

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