Billing for non-physician practitioners (a term used by CMS) or NPPs (e.g., physician assistants, certified registered nurse anesthetists, nurse practitioners, etc.) varies based on licensure of the provider, on the payer, the place of service and specific services being rendered. Incorrectly billing for non-physician practitioners can trigger a payer audit. Some of the biggest issues related to NPP billing have to do with the concept of “Incident to.”
Two Ways to Bill
- Medicare and many commercial payers allow NPPs to be credentialed providers so they can bill directly to the payer under their own NPI. Often with direct billing, the reimbursement for the NPPs is lower than the reimbursement for the same service rendered by a physician. For Medicare, the rate for NPs and PAs is 85% of the physician fee schedule; for other NPPs the reimbursement is 80%.
- In contrast, services provided as “incident to” are billed under the physician’s NPI and are reimbursed at 100% of the physician fee schedule. “Incident to” services are billed as if the physician personally provided them. Although not actually provided by the physician, “incident to” services must be performed under the direct supervision of the physician.
NOTE: The supervision requirements set forth by the Centers for Medicare and Medicaid Services (CMS) are for billing purposes. If a NPP is billing direct, supervision is not required, unless mandated by state licensure and law.
“Incident to” billing guidelines were developed by Medicare, but other insurance carriers may not necessarily follow Medicare’s lead. For example, some payers may require that all practitioners bill under his/her own NPI. Therefore, it is important to check with each of your payers before billing “incident to.”
Update: As of June 1, 2019, Blue Cross and Blue Shield of Louisiana no longer allows NPPs to bill “incident-to.” They must bill direct.
Recommendations and Strategies for NPPs:
- Consider credentialing all NPPs with the payer, regardless of whether the services are being billed “incident to” or through the NPP’s own individual NPI.
- Know what services can and can’t be billed as “incident to.” For example, services rendered in a hospital or SNF cannot be billed under “incident to,” but services in a physician practice can. Initial E and M codes cannot be billed “incident to,” but established patient visits can if a new diagnosis or plan of care is not part of the visit.
- Document “incident to” services as mandated by each payer and always:
- Identify the individual who rendered the service
- Document the physician’s presence in the office at the time of the service
- Clearly link the services of the NPP to services of the supervising physician. This link may be evidenced by a co-signature; legibly identify credentials of both the NPP and the supervising physician on documentation entries or reference and documentation from other dates of service.
- Know your state’s laws and regulations for the collaboration and supervision requirements with NPPs. Make sure the NPPs function within the scope of their practice in your office. The physician must have a documented Collaborative Agreement for NPs and a Delegation Agreement for PAs.
Medicare Resources on “Incident to”
Novitas Solutions, the MAC (Medicare Administrative Contractor) for Medicare in Louisiana, Arkansas and Mississippi provides many resources on “incident to” billing including an “Incident to” Self-Service Tool.
CMS also has a booklet on the basics of billing for Advanced Practice Registered Nurses, Anesthesiologist Assistants and Physician Assistants.
LAMMICO includes $10,000 of MEDEFENSE™ Plus/Cyber Liability coverage, which covers defense costs, regulatory fines and penalties for actual or alleged billing errors, in most provider policies at no additional cost to the insured. LAMMICO offers the option to purchase higher limits of protection through our subsidiary agency, Elatas Risk Partners.
Through our Practice Solutions program, we provide education on Revenue Cycle Management, which consists of revenue cycle operations and related processes in a physician practice with coding, billing and collections being at the core. If a patient is unhappy in any way with the care they received, billing errors or aggressive collection activities could undermine the physician-patient relationship and become the impetus for the patient to file a malpractice claim. Effective revenue cycle management can help mitigate your malpractice and compliance risks.
Practice Solutions is a resource for physician practice managers, administrators and staff as well as clinicians. If you are interested in learning more about Practice Solutions or would like to schedule a consultation specific to your Revenue Cycle, contact LAMMICO Practice Management Specialist, Natalie Cohen, MBA, MHA, at 504.841.2727 or email@example.com.