In most medical offices, Nurse Practitioners and Physician Assistants are becoming more common. Nurse practitioners with a Master's or Doctor of Nursing Practice degree are known as NPs (DNP). PAs are certified (PA-C) and typically have a Master's degree. Medical Billing practises employ these mid-level providers for a variety of reasons:
Salary costs are lower (as compared to a physician)
Cut your overhead costs.
Increased patient volume
Insurance and liability costs are lower.
For these non-physician providers, Medicare offers three primary categories of reimbursement (NPPs).
Direct Deposit
When an NPP has their own Provider Identification Number, it is referred to as direct pay (PIN). The NPP (or practise) is reimbursed at 85% of the billable physician rate. It's critical that each of your mid-level providers has his or her own National Provider Identifier (NPI) and is credentialed with each payer so that he or she can bill under his or her own PIN number, if possible, according to payer laws and regulations. However, many payers refuse to certify NPPs. When the "supervising physician" is either not on site or has not provided any care or input into the patient's plan of care, having the NPP credential allows practises to bill insurance companies directly.
"As a result of"
Outpatient services delivered in a physician's office located in a separate office or in an institution, or in a patient's home administered by a non-physician practitioner, are billed as "incidental to" billing (NPP). The physician bills and collects 100% of Medicare's allowed reimbursement with incident to billing. When an NPP meets a patient for whom the physician has done the initial service and established a Plan of Care or treatment plan, this billing method is employed. For this sort of billing, there are special requirements: the physician must be present on site, in the suite rather than just in the building, and give direct supervision (the rules for home visits varies).
For care provided by a qualified NPP, the physician can collect 100% of the Medicare Physician Fee Schedule (MPFS) instead of 85 percent of the MPFS by filing a claim "Incident to." New patients should see a physician to establish a Plan of Care, which would be billed through the rendering physician. The NPP can give follow-up care based on the Plan of Care after the initial visit, paying for direct care as "Incident to." If changes to the plan of treatment are made, such as medication changes, the physician should meet the patient in person to revise the initial plan of care; otherwise, the visit may not be eligible for "Incident to" billing.
Because Medicare originated "Incident to" billing and not all commercial insurance carriers follow Medicare criteria, knowing payer regulations surrounding "Incident-to" billing is critical before providing patient care.
Expenses that are split or shared
"A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient in which the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service," according to the Medicare website. All or part of the history, exam, or medical decision-making important components of an E/M visit make up a substantial percentage of an E/M visit. The qualified NPP and the physician must work in the same group practise or for the same company."
Billing for shared/split services allows the practise to charge under the qualified physician rather than the NPP, which pays a lower rate. Billing for shared/split services provides for an extra 15% reimbursement as long as the criteria are met.
In this form of billing, documentation is crucial. To prove compensation under the split/share criteria, which allow both parties to bill for services, each practitioner must thoroughly document the care they provided.
Shared/split visits are appropriate for services delivered in the following contexts, according to the Centers for Medicare and Medicaid Services (CMS):
Inpatient or outpatient care in a hospital
The emergency room
Observation in the hospital
Discharge from the hospital
When the "incident-to" criteria is met, the office or clinic is used.
Visits that are shared or split are not permitted:
In the context of a skilled care institution or a nursing home
For the purpose of consultation
In the case of critical care services
In terms of procedures
At a patient's residence or domiciliary location
Conclusion
The demand for Nurse Practitioners and Physician Assistants is stronger than ever, thanks to changes in healthcare spending, patient care, and reimbursement, as well as physician shortages. It is vital to have a thorough awareness of each payer's billing and reimbursement policies. Requirements for charting and documentation must be met.
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