Cynthia Swanson (cswanson@seimjohnson.com) is a Senior Manager in Healthcare Consulting at Seim Johnson, LLP in Omaha, NE.
Billing Medicare for services performed by nurse practitioners (NPs) or physician assistants (PAs) seems fairly straightforward. It should be noted, however, there are three options for reporting/billing NP and PA services to Medicare. To assist with ongoing compliance efforts and risk minimization, each option requires a clear understanding of Medicare’s guidelines. To bill under their own names, NPs and PAs must have their own National Provider Identifier (NPI) number.
What are the three options for reporting/billing NP/PA services to Medicare?
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Report as an “incident-to” service
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Report as a split/shared service
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Report under the NP’s name/NPI or PA’s name/NPI
Background
Incident-to services have specific requirements that must be fulfilled in order to bill Medicare, including:
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The NP or PA must provide services that are an integral, although incidental, part of the physician’s personal professional service.
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The NP or PA may be an employee, independent contractor, or a contractor under an indirect contractual arrangement.
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The physician must first see the patient and develop the plan of care that the NP or PA will carry out.
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The physician must remain active in the patient’s ongoing treatment.
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Direct physician supervision is required.
Incident-to is not applicable to:
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New patient office visit services
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Established patients being seen for a new problem/condition (i.e., physician has not seen the patient and established a plan of care for the new condition)
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Consultation services
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Services performed in an institutional setting (e.g., hospital inpatient/outpatient setting, emergency department (ED), skilled nursing facility (SNF))
When Medicare incident-to requirements are met, the service may be billed under the physician’s name/NPI, and Medicare will reimburse 100% of Medicare physician fee schedule (MPFS) amount. If the services are billed under the NP’s name/NPI or PA’s name/NPI, Medicare will reimburse 85% of the MPFS amount.
Split/shared evaluation and management (E/M) services
Split/shared services is a Medicare concept allowing both the physician (MD/DO) and the NP or PA from the same group practice (i.e., they use the same tax identification numbers) to each provide a portion of the evaluation and management (E/M) service.[1] A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NP or PA each personally perform a substantive portion of an E/M visit face-to-face with the same established patient in the office setting on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam, or medical decision-making components of an E/M service.[2]
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The split/shared designation applies only to selected E/M visits and service locations. It is not applicable to new patient E/M visits, consultation services, critical care services, procedures, or nursing facility services.
When Medicare split/shared E/M service requirements are met, the E/M visit may be billed under the physician’s name/NPI, and Medicare will reimburse 100% of MPFS amount. Alternatively, if the services are billed under the NP’s name/NPI or PA’s name/NPI, Medicare will reimburse 85% of the MPFS amount.
Services billed under NP’s name/NPI or PA’s name/NPI
Of the three available options for reporting NP/PA services to Medicare, billing under the NP’s name/NPI or PA’s name/NPI is thought to be the easiest, with potentially fewer compliance risks. Services performed and documented by an NP or PA are applicable to:
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New patient E/M visits
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Established patient E/M visits
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Consultation services
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Hospital inpatient and outpatient services
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ED services
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In-office procedures (when the requirements for supervision are met)
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Other services
When Medicare billing and documentation requirements are met, services are billed under the NP’s name/NPI or PA’s name/NPI, and Medicare will reimburse 85% of the MPFS amount.
Medical record documentation requirements
Medical record documentation requirements depend on how NP and PA services are being performed, where services are performed, and how services are being reported and billed to Medicare.
When billing E/M services under Medicare’s incident-to provisions, medical record documentation should routinely support that:
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The patient was first seen by a physician who developed the plan of care that the NP/PA will carry out,
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The physician continues to be active in the patient’s ongoing treatment,
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The services are for an established E/M visit, and
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The E/M components for the applicable E/M level of visit are performed and documented by the NP/PA. Direct supervision by a physician or member of a physician group is required.
When billing E/M services under Medicare’s split/shared services concept, documentation will vary depending on the place of service where the split/shared E/M visit is performed. In the office setting, medical record documentation should routinely support the patient was first seen by a physician who developed the plan of care the NP/PA will carry out, the physician continues to be active in the patient’s ongoing treatment, services are for an established E/M visit, and which E/M components were performed and documented by the NP/PA and which E/M components were performed and documented by the physician. Direct supervision of the NP/PA by a physician or member of a physician group is required.
When a physician and NP or PA provide split/shared services in the hospital inpatient, hospital outpatient, or ED, medical record documentation must support that both the physician and the NP or PA each personally performed part of the E/M on the same date of service. The physician and NP or PA should each document the part(s) that he/she personally performed. If documentation does not show both parties performed a face-to-face portion of the E/M, the E/M visit should be submitted under the NP or PA name/NPI. Notes documented by the NP or PA, then later reviewed and co-signed by the MD/DO, do not satisfy the split/shared requirements.[3]
Compliance concerns
A few examples of improper billing/reporting of NP/PA services include:
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ED services billed under the name/NPI of a physician when, in fact, the services were performed and documented solely by the NP or PA.
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New patient E/M visits were billed under the name/NPI of a physician, when in fact the services were performed and documented solely by the NP or PA.
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Hospital E/M subsequent visits were billed under the name/NPI of a physician as a split/shared service, when medical record documentation does not support a face-to-face portion of the E/M service was performed by the physician.
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Office E/M visits were billed under the name/NPI of a physician as an incident-to service when physician supervision requirements were not met.
Tips for compliant reporting and billing of NP/PA services
To achieve compliant reporting and billing, consider these starting points for your organization:
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Numerous resources are available from CMS and your Medicare Administrative Contractor regarding the billing/reporting of NP/PA services and applicable documentation requirements.
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Credentialing, provider enrollment, and billing/reporting guidelines vary by insurance companies and states. As such, both NPs/PAs and physicians need to stay current with practice guidelines and related ongoing changes.
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At a minimum, annually review internal policies/procedures regarding NP/PA billing/reporting of services to determine if revisions or updates are needed. Communicate any applicable changes with all practitioners and staff.
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Periodically, perform internal or external chart reviews to ensure NP/PA services are being properly documented and accurately billed according to internal policies/procedures.
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Discuss review findings and recommendations with practitioners and staff to help ensure ongoing monitoring, education, and compliance program efforts.
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If billing errors are identified, follow internal policies/procedures specific to determinations related to voluntary repayment obligations.
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Maintain internal records and documentation of all chart reviews performed and ongoing compliance education provided to practitioners and staff.
Takeaways
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Understand the three options for reporting NP/PA services to Medicare.
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Develop practice protocols for reporting and billing NP/PA services.
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Provide ongoing education/communications to practitioners regarding expectations for Medicare compliance and medical record documentation.
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Use Medicare’s guidelines and apply them according to the process by which NP/PA services are billed by your organization.
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Payment policies and billing for NP/PA services are often addressed differently by various payers.