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Coding and billing for advanced practice clinicians


Nurse practitioners, physician assistants, and other advanced practice clinicians may have different coding requirements, adding another layer of complexity to the coding process.

A 67-year-old patient with diabetes shows up for her appointment. Her A1C levels are high. She reveals during the visit with the advanced practice clinician that she’s not taking her medication as prescribed. The patient’s physician is doing rounds at the hospital and is, thus, unavailable to consult with the patient in person.

At this point, the practice needs to answer a couple questions:

  • Can the nurse practitioner (NP) or physician assistant (PA) bill the visit under his/her own national provider identification (NPI) number?
  • Or, is the visit appropriate for “incident to” billing and, thus, billable under the physician who created the patient’s care plan?

It depends, says Kim Huey, CPC, president of Birmingham, Ala.-based KGG Coding and Reimbursement Consulting, which helps physician practices improve coding and documentation of service as well as ensure compliance with Medicare and insurance company regulations.

If the physician only recommended metformin in the care plan, and that medication hasn’t been used by the patient, the advanced practice clinician needs to create a new plan of care or bring another physician into the patient’s room to develop a plan of care, Huey says. In the first scenario, the practice can bill Medicare 85 percent for the visit because it’s billed under the advanced practice clinician, whereas in the second, Medicare is billed 100 percent because the newly-introduced physician developed the plan of care upon conducting a visit with the patient.

However, if the physician who created the initial care plan included a variety of options, such as different medications to treat the patient’s diabetes, the advanced practice clinician can choose from one of the provided options and still bill the encounter as “incident to.” And that means the practice can bill the encounter at 100 percent of the physician’s rate, Huey says.

Practices around the country struggle to learn and apply the nuances of “incident to” billing-in addition to keeping tabs on the documentation needs of various private payers regarding advanced practice clinicians. Here are five things practices need to keep in mind regarding coding and billing for physicians and nonphysicians on their clinical team.


Understand “incident to” billing

CMS defines “incident to” billing as “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 home.” To qualify as “incident to,” services must be part of the patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the patient’s care.

The physician doesn’t have to be in the exam room while services are provided during subsequent visits, but the physician must provide direct supervision. That means the physician must be in the office suite for clinical decision-making should the care plan change. CMS also requires the patient record includes documentation of essential requirements for “incident to” service.


Exercise caution

Practices should exercise caution in the way they structure and document patient visits if they want to bill encounters as “incident to” the initial physician’s plan of care.

Specifically, this means the physician must conduct the entire new patient visit; however, another clinician can conduct a review of systems with the patient. If, for example, a patient with hypertension returns to the practice-after an initial visit with the physician-and sees the NP, that encounter can be billed under the physician.

Huey, who conducts insurance compliance audits at physician practices, says NPs and PAs should document in the EHR they’re providing care to the patient that follows the physician’s care plan.

If they don’t, there can be consequences. She’s working with a practice that’s settling with the U.S. attorney’s office on a billing-related issue. The problem? It wasn’t clear from patient records that the NP had even consulted the physician’s care plan during the patient visit.

Focus on the patient

Or, you can just focus on the patient’s needs instead of spending so much time worrying about satisfying “incident to” requirements, says Sondra DePalma, a York, Penn.-based PA and director of regulatory and professional practice at the American Academy of Physician Assistants.

Here’s how that plays out at practices: If the physician must be doing rounds at the hospital-and that’s what’s best for patient care-then that’s where the physician should be. The physician shouldn’t be at the practice just so he/she can be brought into the exam room to change a patient’s care plan.

As a PA, DePalma says she can help generate more revenue for the practice by seeing patients even if the practice only makes 85 percent of what it could make for encounters billed as “incident to” a physician’s care plan. That makes sense, since there are only so many appointment slots available in a physician’s schedule in a given week. If she weren’t there, the practice wouldn’t be able to treat as many patients, meaning it would be losing out entirely on the 85 percent of what she is billing for.

“You can actually increase revenue and access to care,” DePalma says by focusing on what the patient needs in the exam room; empowering NPs and PAs to provide that care and bill for it; and not worrying about whether the physician is in the office suite.


Reveal “hidden” providers

One compelling reason to have the practice’s PAs and NPs bill under their own NPI number is so public and private payers know who is providing the care.

Joyce Knestrick, PhD, APRN, president of the American Association of Nurse Practitioners, advocates for discontinuing the practice of NPs billing under physicians. “We think these services should be amended by regulations or guidance so that NPs would bill everything as their own ID for the services they provide. If they don’t, they remain hidden providers.”

This practice is problematic from a quality point of view, she says. For example, if the NP conducts the vast majority of the visit and the physician comes by to say “hi” to the patient and the practice bills the visit under the physician, the NP “disappears.” CMS doesn’t know who provided care for the patient.

Creating a “tag” within the patient record to indicate the name of the clinician who conducted the visit could help with tracking and reporting this information, says Knestrick, a family nurse practitioner in Pittsburgh.


Be aware of Medicaid and private payer requirements

Another area of complexity for practices is with Medicaid since each state has its own laws governing its program. Knestrick says some states require that the physician must be on-site and include such supervisory language in their regulations. There are also states where NPs can practice and bill autonomously for both new patient and follow-up visits.

In addition to government payers, each private payer can have its own rules about advanced practice clinicians and billing. Huey cites, for example, a major payer in Alabama that requires patient visits to be billed under the clinician who documented the history of present illness, “which isn’t even the ‘meat’ of the visit,” she laments. Private payers can even choose not to cover visits conducted by NPs and PAs at all, so those patients must be seen by a physician.

Clinicians are busy with patients, and they don’t have much time to learn the changing billing requirements of each payer. That’s why Huey recommends developing a matrix with the requirements of the practice’s top three or four payers-and make it available to all clinicians who conduct patient visits.

Aine Cryts is a Boston-based healthcare writer.

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