Nurse Practitioners: Navigating The Insurance Billing Maze

Billing insurance as a nurse practitioner is a complex process that requires a good understanding of the rules and regulations. The billing process can vary depending on whether the nurse practitioner is billing independently or as an employee of a physician or group practice. In the United States, Medicare is a major insurance provider that reimburses nurse practitioners for their services. The reimbursement rate for nurse practitioners is typically 85% of the physician fee schedule. However, when billing incident-to a physician's service, nurse practitioners can receive 100% of the physician fee schedule rate. This incident-to billing requires certain conditions to be met, such as direct supervision by the physician and initiation of the treatment plan by the physician. Private insurance companies may have their own rules for credentialing and reimbursing nurse practitioners, so it is important to understand their policies. Understanding billing and coding guidelines is crucial for nurse practitioners to ensure proper reimbursement for their services.

Medicare's incident-to billing rules

• The services must be an integral, yet incidental, part of the physician's professional service in the course of diagnosis or treatment of an injury or illness.
• The services must be of a type commonly furnished in a physician's office or clinic.
• The services must be provided under the direct supervision of the physician, who must be present in the office suite and immediately available to provide assistance and direction.
• The physician must perform the initial service and subsequent services of a frequency that reflects their active participation in managing the course of treatment.
• The physician or other provider under whose name and number the bill is submitted must be present in the office suite when the service is provided.

It is important to note that not all services qualify for incident-to billing. For example, hospital and skilled nursing facility services cannot be billed as "incident-to" at any time. Additionally, incident-to billing cannot be used for a patient's first visit or if there is a change to the plan of care. In these cases, a physician must conduct an initial evaluation and management service, establish the diagnosis and plan of care, and the services must be billed under the NPP's name.

Incident-to billing can provide financial benefits to medical practices by allowing for higher reimbursement rates. However, it is crucial to follow the rules and regulations set by Medicare and other payers to avoid audits, fraud allegations, and penalties.

Direct billing

To bill Medicare for NP services (other than incident-to services), the NP needs a performing provider number, which can be obtained from the Medicare carrier. NPs can either bill Medicare directly under their own provider numbers or reassign their billing rights to employers or other contracting entities.

It is important to note that Medicare will not pay twice for the same NP service. For example, if an NP employed by a hospital treats a Medicare patient, Medicare will not pay the hospital under Part B for those services if it has already paid the hospital for the NP's services under Part A.

In summary, direct billing offers NPs more autonomy and a higher reimbursement rate compared to indirect billing or incident-to billing. However, it is subject to the insurance carrier's credentialing and acceptance of claims submitted under the NP's provider number.

Shared visits

In general, shared visits are applicable in hospital inpatient or outpatient settings, emergency departments, and hospital observation units. They are not allowed in skilled nursing facilities, for consultation services, or for critical care services.

To bill for a shared visit, the physician and NPP must be in the same group practice or employed by the same employer. The physician must provide a face-to-face portion of the encounter and personally document their involvement in the patient's record. The NPP must also document their portion of the visit. The visit can then be billed under the physician's provider number and reimbursed at 100% of the physician fee schedule, rather than the lower rate that would be paid if billed under the NPP's provider number.

It is important to note that the specific requirements for shared visits may vary by payer, so it is essential to understand the rules and regulations of each insurance company or program. For example, Medicare has specific guidelines for shared visits, which include the requirement that the physician and NPP be in the same group practice or employed by the same employer. Additionally, Medicare requires the use of a specific modifier to identify claims for shared visits, which has not yet been identified.

Proper documentation is crucial for shared visits. Both the physician and the NPP must clearly document their respective portions of the visit, including the specific components they performed (history, exam, or medical decision-making). The individual who performed the substantive portion of the visit must also sign and date the medical record. This documentation ensures compliance with billing requirements and helps to justify the level of service reported on the claim.

Billing for split/shared services

Split/shared services refer to when a patient is seen by both a physician and a non-physician practitioner (NPP) on the same day. This can include nurse practitioners, physician assistants, clinical nurse specialists, and certified nurse-midwives. The Centers for Medicare & Medicaid Services (CMS) allows these visits to be combined and reported under a single provider's name if the shared/split billing criteria are met and appropriately documented.

The physician and the NPP must be part of the same group practice, either through direct employment or a leased arrangement. The NPP must be an employee or independent contractor of the supervising physician, the physician's group, or the physician's employer. The physician must be in the same office suite and immediately available to provide direction.

For a shared/split service to be billed under the physician's name and provider number, the physician must perform some aspect of the evaluation and management (E/M) service with a face-to-face patient encounter and document their portion of the service in the patient's record. The physician's documentation must clearly indicate that a face-to-face visit took place. Both practitioners must document and sign for the work they perform.

The shared/split billing option only applies to selected E/M visits in explicit facility-based settings: emergency departments, outpatient hospital clinics, or inpatient hospitals. It does not apply to critical care services, procedures, consultations, or services in skilled nursing facilities or nursing facilities.

The substantive portion of the E/M visit can be determined by the practitioner who spent more than 50% of the time or who made or approved the medical decision-making. The combined service level reported on the claim must be supported by the documentation.

Billing for shared/split services allows the practice to bill under the qualified physician instead of the NPP, resulting in a higher reimbursement rate.

Billing for home visits

Understanding Medicare's Incident-to Billing:

Medicare allows "incident-to" billing, where services provided by a supervised NP can be submitted under a physician's provider number. This means that if an NP conducts a home visit as part of a physician's service, the practice may be reimbursed at 100% of the Physician Fee Schedule rate. However, certain rules must be followed:

• The NP must be an employee of the physician or the group that employs the physician.
• The physician must perform the initial service and initiate the plan of care that the NP is carrying out.
• The physician must remain involved in the patient's care and document this involvement.
• The physician or another employed physician must be in the same office suite and immediately available to provide backup.
• The service must be provided in the patient's home.

Direct Billing for NPs:

NPs can also bill Medicare directly for their services, and Medicare pays 85% of the physician fee schedule in such cases. To bill Medicare directly, the NP must have their own provider identification number (PIN) and be credentialed with each payer. This allows practices to bill insurance companies directly when the supervising physician is not on-site or has not provided any input into the patient's plan of care.

Billing for Shared/Split Services:

In some cases, billing for shared/split services may be applicable. This is when both the physician and the NP personally perform a substantive portion of an evaluation and management (E/M) visit with the same patient on the same day. Billing for shared/split services allows the practice to bill under the qualified physician instead of the NP, resulting in a higher reimbursement rate. However, this requires thorough documentation from each practitioner to substantiate reimbursement.

Home Visits and Medicare Part A and B:

It's important to distinguish between Medicare Part A and Part B when billing for home visits. Part A covers inpatient hospital stays, skilled nursing facility services, hospice care, and some home health services. Part B covers physician services, outpatient hospital services, medical supplies, and preventive services. NPs may bill Medicare Part B for services that would be considered physician services if they fall within the NP's scope of practice.

Home Visits and Nursing Services:

If an NP is providing nursing services billable under Medicare Part A during a home visit, they would need a physician's order for the visit, and the visit must be conducted through a Medicare-certified home health agency. The agency would then submit the bill and receive payment under the prospective payment system.

Home Visits in Nursing Homes and Skilled Nursing Facilities:

In a nursing home or skilled nursing facility, an NP may perform the admission evaluation if state law authorizes them to do so and a physician delegates that function. In a skilled nursing facility, an NP may alternate conducting "required physician visits" with a physician, provided the state authorizes it, the NP is not employed by the facility, and they are working in collaboration with a physician.

Home Visits and Hospitalized Patients:

NPs can provide physician services to hospitalized patients if it falls within their scope of practice under state law or if a physician delegates the authority. However, a physician must be involved in the process of care for hospitalized patients. The services must be billed under the NP's provider number unless the rules for "shared visits" are followed, in which case the services may be billed under the physician's provider number.

Home Visits and Medicare Advantage:

Medicare Advantage, the Medicare managed care program, does not specifically address NPs in its reimbursement laws. Reimbursement is made under the terms of contracts between Medicare and the managed care plan, and between the plan and the physician group. Managed care plans may or may not admit NPs to their provider panels and may have different policies regarding reimbursement for NP services.

Frequently asked questions