Pulmonology Coding Alert

Question:  If one of our NPs does an outpatient procedure, and the physician is present during the procedure, should I bill it under the NP or the physician?

Nevada Subscriber

Answer: It depends. You will bill it according to the exact coverage of the Health plan in question as the rules of billing and reimbursing for the services of Nursing Practitioners (NP), Clinical Nurse Specialists (CNS), Non-Physician Practitioners (NPP) and Practice Assistants (PA) vary from one plan to another.

While some plans allow NP services to be billed under their own provider numbers, other plans do not and healthcare providers have to bill for the same services using the physician’s name and provider number on the claim. Medicare terms this arrangement as “incident-to” billing. Therefore, you have to carefully go through the policy of each health plan with which the patient has contracted for the billing policy, or identify the terms of agreement negotiated between the practice and the payer.

Even though NPs and CNS may obtain their own Medicare billing numbers, you will bill the Medicare services under physicians for outpatient services provided by the NP only if the following conditions have been fulfilled: 

• ­­­The NP must be an employee of the physician. (The NP can be either a routine employee or leased employee from another agency; he or she must not be an independent contractor.)
• The physician sees the patient in the initial visit. (This means the physician has to repeat essential elements of the physical exam and review the history. He or she needs to make a separate note in the chart. There cannot be just repetition for formality.)
• The physician has an active and ongoing involvement in the patient’s care. (Nothing specific is defined, but generally, this implies that the physician sees the patient for any new significant problem and, otherwise, every third to fifth office visit.)
• The physician directly supervises the NP. (It is not necessary for the physician to see the patient, but the physician should be in the office suite at the time the service is being rendered and available to render immediate assistance if required. Just being present in the building is not sufficient.)
• The services are allowed to be performed as an “incident-to” service (otherwise, it will have to be reported under the NP name to those payers that allows this).
• The service takes place if an “office” setting (Place of Service 11) (otherwise, it will have to be reported under the NP name to those payers that allows this).

Note: Billing Medicare for services provided by NPs under the physician’s name as “incident to” is a risky practice unless the physician is always present in the office suite when the NP sees patients. This type of billing does not apply to inpatient situations and only applies to ambulatory care in a private office setting. Incorrect billing can lead to significant financial penalties, and a consistent pattern of improper billing can lead to criminal charges of fraud. This is not a matter to take lightly.