Billing by Non-Physician Providers (NPPs)

A non-physician provider (NPP) is a healthcare provider who is not a physician but who practices in collaboration with or under the supervision of a physician. NPPs may bill payers directly, rather than billing under a physician, in certain circumstances. Examples of NPPs include physician assistants (PAs); advanced practice registered nurses (APRNs); nurse practitioners (NPs); clinical nurse specialists (CNSs); certified nurse midwives (CNMs); and certified registered nurse anesthetists (CRNAs). There are three main approaches for billing by Non-Physician Providers (NPPs) described below.

1. Direct Billing by Non-Physician Providers

NPP’s must be enrolled and receive their own national provider identifier (NPI) in order to directly bill services. Professional services rendered by certain licensed non-physician providers or NPPs may be billed directly to the Medicare program, provided that the services are within the NPP’s scope of practice, as defined by State law. NPP’s who are eligible for direct billing include, but are not necessarily limited to NPs, CNSs, CRNAs, and CNMs.

On the other hand, most licensed and registered nurses and most technicians’, are not eligible for direct billing. NPPs may be employees or independent contractors of a physician or physician group practice, for the physician or group practice to bill for their services. PAs, may not bill their services directly to Medicare. Medicare generally pays PAs, NPs, and CNSs at 80 percent of the lesser of the actual charge or 85 percent of physician payment under the MPFS.

2. Incident to Billing by Non-Physician Providers

Under certain circumstances, services furnished by NPPs may be billed under a physician’s provider number as ‘incident to’ the physician’s services. A physician or other authorized practitioner (including PAs, NPs, and CNSs) may supervise certain other employees who provide services incident to the physician or other practitioner’s services. The supervising physician or other supervising practitioner then bills for that incident-to-service using their NPI. Unlike direct billing, an NPP need not have his or her own provider identification number in order for services furnished by the NPP to be billed as ‘incident to’ a physician’s services.

NPP services performed ‘incident to’ a physician’s services are eligible for 100 percent reimbursement when billed under the supervising physician’s NPI, as opposed to the 85 percent payment services earn when billed under the NPP’s NPI. To be covered as an “incident to” the services of a physician, the services must be:

  • An integral, although incidental, part of the physician’s professional service;
  • Commonly rendered without charge or included within a physician’s bill;
  • Of a type that is commonly furnished in a physician’s office or clinic; and
  • Furnished under the physician’s direct supervision. Direct supervision requires the physician to be present within the office suite and immediately available to furnish assistance and direction throughout the service. The physician need not be present in the room with the patient and NPP during the service, but must be in the office suite and immediately available.

For a service furnished by an NPP to be covered as ‘incident to’ the services of a physician, there must have been an initial first service, a direct, personal, professional service, furnished by the physician to begin the course of treatment of which the service being performed by the NPP is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment.

Services must be performed by an employee, leased employee, or independent contractor of the physician or an employee of the entity that employs the physician. Physicians are not required to countersign clinical notes entered by NPPs for claims submitted under the ‘incident to’ provision for reimbursement reasons but may be asked to do so for the quality of care considerations. Documentation should contain evidence that the supervising physician was actively involved in the care of the patient and was present and available during the visit.

3. Shared/Split Visits Billing by Non-Physician Providers

A shared/split 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. The split/shared E/M visit applies only to selected E/M visits and settings. The split/shared E/M policy does not apply to consultation services, critical care services, or procedures. These services will be reimbursed according to the billing provider. If the NPP billed the services it will be 85% of the Physician’s fee schedule. If billed by the physician it will be reimbursed at 100% of the Physician’s fee schedule.

Office/clinic setting: When an E/M service is a shared/split service between a physician and an NPP, the service is considered to have been performed ‘incident to’ if the requirements for ‘incident to’ are met and the patient is an established patient. In this case, the service is reported using the physician’s unique physician identification number (‘UPIN’)/provider identification number (‘PIN’). If the requirements for ‘incident to’ are not met, the service must be billed under the NPP’s UPIN/PIN.

Hospital setting: When a hospital inpatient/outpatient or emergency department E/M service is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician’s or the NPP’s UPIN/PIN. However, if there was no face-to-face encounter between the patient and the physician, the service may only be billed under the NPP’s UPIN/PIN. For example, if the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, either the physician or the NPP may report the service.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. You can call us at: 888-357-3226 or email us at: info@medicalbillersandcoders.com to know more about non-physician providers (NPPs) billing.