Healthcare Fraud Shield’s Latest Article: Billing for Non-physician Practitioner (NPP) Services

2 Aug

It’s common to walk into a medical office and find nurse practitioners and/or physician’s assistants providing care to patients, alongside of physicians.  Non-physician practitioners (commonly referred to as NPPs) such as Physician Assistants (PAs) and Nurse Practitioners (NPs) are employed to improve access and reduce health care costs.  NPPs are not only found in primary care settings, but in specialty practices such as pediatrics, urology and neurology.   Although NPPs provide many of the same services as a physician, they are usually reimbursed at a lower rate as compared to a physician providing the same service.   For example, Medicare reimburses NPPs for covered services at 80 percent of the lesser of the actual charge or 85 percent of what a physician is paid under the Medicare Physician Fee Schedule[i].

Not only are NPPs usually paid at a lower rate, there are also different methods to bill for their services.  Medicare allows physicians to report themselves as the rendering physician and be reimbursed at the physician rate, for services rendered by the NPPs when certain criteria are met.  This is referred to as “incident to” billing.  Per the Medicare Benefit Policy -Chapter 15[ii], services rendered by NPPs are supported as incident to when they are:

  • An integral part of the patient’s treatment course during which a physician personally performed an initial service and remains actively involved in the course of treatment;
  • Commonly rendered without charge (included in the physician’s bill);
  • Of a type commonly furnished in a physician’s office or clinic; and
  • An expense to the physician

If all of the above requirements are not met, NPs must bill Medicare directly using their own NPI. The services of a PA, however, are to be billed by an employer and the PA’s NPI is used for identification purposes.

Additionally, many payers require the appropriate modifier be appended to the claim for services rendered by NPPs.  For example, The Indiana Health Coverage Programs Providers Manual,[iii] which provides billing guidance for services rendered by non-physician practitioners, requires that services furnished by an NP are billed with the SA modifier.  Likewise, services furnished by an PA must be billed with either the HN (bachelor’s degree) modifier or the HO (master’s degree) modifier, applicable to the level of education of the PA.

Policies and practices for billing for NPP services will vary from payer to payer so always check with each specific payer on how these services should be billed.

[i] Medicare Claims Processing Manual Chapter 12 – Physicians/Nonphysician Practitioners

[ii] Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services

[iii] Indiana Health Coverage Programs Providers Manual, Chapter 8: Billing Instructions, Published December 4, 2014

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