Making the Most of Non-physician Practitioner Revenue

By Belinda S. Frisch, CPC

Non-physician practitioner (NPP) billing continues to be a source of industry confusion. There are three ways to bill Medicare for NPP services (nurse practitioners and physician assistants): billing incident-to, reporting shared/split visits, or using the NPP’s own provider number.

CPB : Online Medical Billing Course

Enroll the NPP

The first step in billing NPP services to Medicare is to enroll the NPP in the Medicare program. Next, based on the type of service, determine the provider number under which you should bill the service. If the reporting criteria are met, services rendered in the physician’s office are covered under the incident-to provision. Incident-to services are billed to Medicare using the physician’s national provider identifier (NPI), even though the services are provided by the NPP. These services are reimbursed at 100 percent of the Medicare Physician Fee Schedule (MPFS) amount. The following criteria must be met in order to bill incident-to outpatient practices.

The service provided must be an integral, although incidental, part of the physician’s personal professional services. To be eligible for incident-to billing, the physician must first see the patient and develop the plan of care that the NPP will carry out. Furthermore, the physician must remain active in the patient’s ongoing treatment.

Note: When the NPP sees a new patient, a patient for consultation, or an established patient with a new problem, the NPP should report his services using his own NPI. Incident-to rules do not apply to these services because the physician has not first seen the patient for the presenting problem or created a plan of care for the patient.

Direct Supervision is Required

The physician must be available in the office suite to assist the NPP if necessary. The physician is not required to be in the room at the time of the examination, but he must be in the office. If the service does not meet incident-to requirements, bill Medicare using the NPP’s provider number. Medicare will reimburse reasonable and necessary services at 85 percent of the MPFS amount.

Shared visits: When both a physician and an NPP provide services in the office on the same day and incident-to requirements are met, the bill can be submitted under the physician’s NPI; if incident-to requirements are not met, you must bill under the NPP’s provider number.

The Bottom Line

NPP billing for services provided to non-Medicare payers depends largely on the payers themselves. Familiarize yourself with your local policies for billing these services by contacting designated provider representatives from each payer.

For more information on billing NPP services to Medicare, consult the Medicare Claims Processing Manual and the Medicare Benefit Policy Manual.


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