Utilizing Nurse Practitioners
Several members have approached the SMFM and inquired about the options for billing for services performed by a Nurse Practitioner.
The way you report the service depends on how the payers have the Nurse Practitioner credentialed. When billing for a Non‐Physician Provider (NPP), you have the following three options;
● Direct billing (Services are reported under the Non‐Physician Provider)
● Incident‐to (Services are reported under the physician in the clinic)
● Shared/Split Billing (Services are reported under the physician or Non‐Physician Provider)
Direct Billing:
- If the Non‐Physician Provider has their own provider number, they can bill directly for their services
- Some payers may decrease reimbursement, although most are now paying 100% of contacted amount.
- Some state Medicaid programs require direct billing for Non Physician Providers.
Incident‐to Billing
- “Incident to” services are defined as those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s house.
- “Incident to” is a Medicare concept intended to allow the physician in an office setting to bill for ancillary‐type services and some limited E/M services performed by a Non Physician Provider (NPP), thus freeing the physician to see other patients at the same time. (See MCR IOM, Pub. 100‐02, Chap 15, Section 60 and Pub. 100‐04, Chap 12, Section 30.6.4).
- Providers included: NP, PA, CNM, CNS and CRNA.
- Require licensing and certification by the state and national certifying agencies.
- Scopes of practice may include a defined level of diagnosing and treatment.
- Physician supervision in some form required in most cases – ranging from written practice agreements to being in‐the‐room.
- Generally receive a reduction from the physician fee schedule rates. Most payers reimburse NPPs at 85%, not 100%, of the physicians contracted rate.
- Physician must provide the initial evaluation and establish a plan of care for the problem/condition
- Physician must see patient intermittently during course of treatment
- If there is any change in the patient status, “Incident to” billing cannot be performed. The physician must see the patient again and set up a new treatment plan.
- Services must be performed in an office/clinic setting, and cannot be used for inpatient care.
- A supervising physician must be in the office and available to assist if needed
- Physician must have financial responsibility for the Non Physician Providers providing services (i.e., W‐2, leased employee, contractor)
Question: The physician spends 15 minutes with the patient. The Nurse Practitioner then spends 30 minutes with the patient on the same day. Can the times of both providers be combined to select the E/M level?
Answer: In order to qualify as “incident to”, the services of two providers cannot be combined. The shared/split visit guidelines would apply.
Question: Can a Non Physician Provider bill “incident to” another Non Physician Provider?
Answer: Since Non Physician Providers (NP, CNM, PA, etc.) have their own provider numbers, it would not be appropriate for one Non Physician Provider to bill under another.
Question: Can a Non Physician Providers bill for “incident to” services performed by auxiliary staff?
Answer: Yes, a Non Physician Provider can bill under their provider number for services provided by auxiliary personnel (MA, LPN, RN), as long as “incident to” criteria are met.
Question: Does the billing provider need to co‐sign the Non Physician Providers note for “incident to” services?
Answer: Billing provider co‐signature is not a requirement for “incident to” services. However, the billing provider is responsible for the accuracy of any claim submitted under his/her name. Therefore, it is encouraged that the billing provider co‐signs all medical record entries made by the Non Physician Provider for “incident to” services.
Shared/Split Billing:
- An encounter with a patient where the physician and a qualified non‐physician practitioner each personally perform a portion of an E/M visit with the same patient on the same date of service, document, and sign the work they each performed. There must be a face-to-face encounter with the physician.
- Must be medically necessary
- Within the Non Physician Providers scope of practice
- The physician and Non Physician Providers are from the same group
- In office/clinic setting must be an established patient (physician performs initial visit)
- Only one claim can be submitted for a shared/split service.
Locations
- Office/clinic
- Hospital (inpatient/outpatient)
- Emergency Department
- Observation
Services
- Evaluation and Management only
Does not apply to
- Consultations
- Critical care services
- Procedures
Does not apply to auxiliary staff or residents
Outpatient clinic/office setting:
- Established patient
- Each provider documents their own service
Inpatient/outpatient hospital setting:
- No distinction between new and established patient
- Each provider documents their own service
Time
- If basing the service on time, you cannot combine the Non Physician Providers and physicians time for the E/M level
- If billing under physician number, counseling by other staff cannot be counted toward the selection of the E/M level
Question: Can the split/shared visit guidelines be applied to a new patient?
Answer: In the outpatient clinic/office setting, the “incident to” guidelines must be met. Therefore, split/shared billing can only be done for established patients. In the hospital setting, there is no distinction between new or established patients.
Question: A Nurse Practitioner from another practice rounds on patient in the morning. I see the patient in the afternoon of the same day. As a physician, can I combine my services with the Nurse Practitioner services to determine the E/M level?
Answer: According to the split/shared visit guidelines, both providers must be from the same group practice.
Question: Do the split/shared services guidelines only apply to E/M visits?
Answer: The split/shared guidelines are only applicable to E/M services, with the exception of consultations and critical care services.
Question: When two physicians from the same practice each perform E/M services on the same date, do the split/shared visit guidelines apply?
Answer: The split/shared visit guidelines only apply to situations where a Non Physician Providers and a physician each perform part of an E/M on the same day. There are other specific situations where the services of two physicians may be combined on the same date of service.
Question: Can I use the split/shared visit guidelines when a resident sees the patient and I see the patient later on the same day?
Answer: The non‐physician providers who qualify under the split/shared visit guidelines are identified as NPs, CNSs, CNMs and PAs. Resident’s do not qualify as Non Physician Providers.
EXAMPLES OF SHARED VISITS
1. 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, the physician or the NPP may report the service.
2. In an office setting the NPP performs a portion of an E/M encounter and the physician completes the E/M service. If the "incident to" requirements are met, the physician reports the service. If the “incident to” requirements are not met, the service must be reported using the NPP’s UPIN Number.
It is important to identify NPP employment relationships, the NPP’s role in the provision of services, the state supervisory or collaborative rules, and local payer interpretations to prevent misrepresentations, misunderstandings, or erroneous reporting.
We hope this information is helpful to you and/or your organization. As always...we strongly suggest you contact your local payers for their specific guidelines on reporting services performed by a Non‐Physician Provider.