Wiki Billing new patient visits under NP

[kellyjseidl@gmail.com]

The question of billing new patient E/M visits and/or new patient prevent visits under our NP license has come up. If the patient has not seen a provider first to establish care, is the NP allowed to bill the new patient visit under her NPI?
For most appointments we bill with NP as servicing provider and the DR as the billing provider.
Any information/advice is appreciated.

 

[csperoni]

To me this sounds like you may be confusing Incident-to billing guidelines with your state's scope of practice.
Each state determines scope of practice for NPs. That is what they are or are not legally allowed to do. I am not aware of any state that does not permit NPs to see new patients. In fact many states allow NPs to practice rather independently.
Incident-to is a BILLING guideline only. In fact it is specifically a Medicare guideline, and commercial carriers may or may not permit incident-to billing. Incident-to is where you are submitting charges for services of an NP/PA/CNM under a physician. There are several requirements that must all be met in order to bill NPP services under a physician including:
1) Established patient with established problem and a plan of care. In this scenario, the NPP is simply following out the already determined plan by the physician.
2) Physician must be on site in the suite and immediately available.
3) Cannot be for services in a hospital or SNF.

https://www.aapc.com/blog/44912-seven-incident-to-billing-requirements/

https://www.aapc.com/blog/87837-billing-a-pas-services-incident-to-a-physicians/

https://www.aapc.com/blog/29608-understanding-incident-to-services/

If the carrier follows incident to and all of the requirements are not met, then the claim simply must be billed under the NPP and not the physician.

If the carrier does NOT allow incident-to billing, then the claim is billed based on their specific policy which could be more or less restrictive. Some policies do not permit the physician to bill even if incident to is met. Some policies permit the physician to bill even if incident to is NOT met. Some may want a specific modifier on any incident-to claim.