Incident-To and Shared Billing Guidelines for Advanced Practice Providers

Twenty years ago, I was serving as Reimbursement Manager for a multi-specialty practice of 28 physicians and 14 non-physician practitioners.  We thought we were billing correctly, and then Medicare changed the way we could bill for services provided by our nurse practitioners and physician assistants.   Our providers – physicians, nurse practitioners, physician assistants – along with administration and billing staff, reevaluated how patients were scheduled, how charges were captured, and how claims were generated in order to bill correctly and achieve optimum reimbursement.  Unfortunately for many practices, there is still much confusion and misunderstanding about billing for the services of Advanced Practice Providers (APP), also known as Non-Physician Practitioners or Mid-Level Providers.

Depending on the setting, Advanced Practice Providers have three options for billing services to Medicare:

  1. Incident-to a supervising physician;
  2. Split/shared with a physician; and
  3. Under their own provider number.

Incident-To a Supervising Physician

Incident-to is a broad billing concept that applies not just to services performed by APPs like Nurse Practitioners and Physician Assistants but also to any service billed under the physician’s supervision.  Incident-to services are billed in the name and provider number of the supervising physician.  Chemotherapy and other infusions as well as nurse visits are billed incident-to.  Any service not personally performed by the physician but billed under his name would need to be billed following the incident-to guidelines.

In order for a service to be billed as incident-to to Medicare, the service must be:

  • Performed as part of the physician’s overall care of the patient, what CMS calls “an integral, though incidental part of the physician’s professional service”. There must be a previous visit by the physician establishing a plan of care that the APP is now following.  The physician must also see the patient on subsequent services of a “frequency which reflect active participation and management.”
  • Furnished in the physician’s office or clinic under direct supervision. The physician must be in the office suite and immediately available.
  • Furnished by an employee of the physician or the same entity that employs the physician.
  • Furnished in compliance with the state scope of practice for the rendering provider.

Some Medicare contractors also require that the supervising physician cosign the encounter note.  As clarified in the Medicare Final Rule for 2016, supervision may be provided by another physician in the group practice, but the services must be billed under that physician as the supervising physician.  The services are then paid as if the physician performed the service.

Payers other than Medicare may have their own definition of incident-to.  Some may not have any specific requirements.  Others may credential APPs and request that the services be billed under that provider number.  Just because a payer uses the term “incident-to” does not mean that it follows the same guidelines.  The best practice will be to check with your major payers to determine what the billing policy is for services performed by APPs.

Split/Shared With a Physician

If incident-to only applies in the physician’s office or clinic, how can APPs work with physicians in the hospital setting? This was the thought that prompted what is known as split/shared billing to Medicare.  If an APP and a physician in the same group practice both see the patient face-to-face in the hospital on the same date of service, the work is combined and billed under the physician.  This applies whether the service is rendered in the outpatient hospital setting, inpatient hospital or Emergency Department.  This provision is very specific and would not apply in any other setting.

Under the APP’s Provider Number

If an APP sees a patient and the requirements are not met for either incident-to or split/shared, then the services must be billed under the APP’s provider number.  For Medicare, those services will be paid at 85% of the physician fee schedule.  Other payers may pay at a different percentage or may restrict the levels of services or CPT® codes an APP may bill.  For example, some state Medicaid agencies will not pay for APP services in the hospital.  Other payers may limit APPs to lower levels of service.  This is one area in which a practice has to know each payer and its policy on Advanced Practice Providers to effectively employ them and bill for their services.

When employing Advanced Practice Providers, a practice must answer several questions.  First of all, what is that provider allowed to do under his/her state scope of practice?  This will be different for the different types of APPs – whether advanced practice nurses or physician assistants.  It may also vary from state-to-state, which may be more of a challenge for practices with multiple office locations. Secondly, what relationship will the APP have with the supervising physician?  If the APP will be seeing his/her own patients, then the services will be billed under the APP’s name and provider number.  If the APP will be seeing patients in conjunction with the supervising physician under his plan of care, then all parties must understand the incident-to and split/shared guidelines to ensure correct billing.  Do the major payers in your area recognize APPs?  Do they follow Medicare guidelines or have their own definition of incident-to?

Educating patients is also a concern.  A patient should understand the role of the APP in the practice and should also be informed of the billing arrangements.  Most patients are very satisfied with the care they receive from APPs, but they should also be aware of the allowance for billing such services under the supervising physician to prevent questions of incorrect billing.

On Friday, Aug 19, 2016, I’ll be presenting an audio session at AudioEducator titled “Incident-to and Shared Billing – Update for Advanced Practice Providers (APPs).” In this session, you’ll get deeper insights on making the most of the assets APPs bring to your practice. Learn about the comparison of billing requirement by payer and tips for finding state licensure and privilege information. Also, get insights on compliance risks, patient relation issues and the 2016 CMS Final Rule on incident-to billing.

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