Billing Rules Applying to Non-Physician Practitioners

Title: Billing Rules Applying to Non-Physician Practitioners
Standard #:


Issued: 06/01/2011 Reviewed/Revision Date:  12/09/2014

I.  Statement of Purpose

The objective of the standard is to provide billing guidance for services with non-physician practitioners (NPP).

II.  Definitions

  • Incident-to – a physician’s professional services means that the services are furnished as an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.
  • Shared/Split – a medically necessary encounter with a patient, where the physician and a qualified NPP each perform a substantive portion of an Evaluation & Management (E&M) visit face-to-face with the same patient on the same date of service.
  • Direct Supervision – requires the supervising physician whose NPI number is being billed is present in the suite at the time of the visit and immediately available to furnish assistance and direction throughout the performance of the service.  It is generally accepted that the office suite in a private office setting is within the four walls and ceiling of the area in which the exam and treatment areas are all contained.  Once a person exits the suite area they would be entering a common public area, be it a hallway, stairway or other suite area.  Office suite, for the purpose of providing incident-to services is further defined by Highmark Medicare pursuant to a memo dated December 2, 2008 to Mercy Health Services from the Medical Director Andrew Bloschichak, M.D., MBA has defined “immediately available as not requiring the supervising physician to enter a public domain to reach the auxiliary personnel that he/she is supervising”.
  • General Supervision – means the service is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure.  Under general supervision, the training of the non-physician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.
  • Place of Service (POS)
    • Inpatient Hospital (POS 21) – A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
    • Outpatient Hospital (POS 22) – A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
    • Emergency Department (POS 23) – A portion of a hospital where emergency diagnosis and treatment of an illness or injury is provided.
    • Office (POS 11) – Location other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.

III.  General Standards for the Provision of Care By Non-Physician Practitioners

USC acknowledges the expanding role of Physician Assistants and Nurse Practitioners and supports their role in a collaborative health care system given the following guidelines.  However certain standards must be met for the proper provision of care and appropriate billing.

  • The Supervising Physician is responsible for supervising Physician Assistants and/or Nurse Practitioners sharing in the care of the patient.
  • Health care services delivered by Physician Assistants and/or Nurse Practitioners must be within the scope of practice, as defined by state law, the medical practice act, and the USC Credentialing Office.
  • The Supervising Physician must be available for consultation with the Physician Assistant and/or Nurse Practitioner at all times, either in person or through telecommunication systems or other means.
  • The extent of the involvement by Physician Assistants and/or Nurse Practitioners in the assessment and implementation of treatment will depend on the complexity and acuity of the
    • patient’s condition and the training, experience, and preparation of the Physician Assistant
    • and/or Nurse Practitioner as determined by the Supervising Physician.

IV.  Billing Requirements For NPP Services in a Hospital Inpatient, Hospital Outpatient, Emergency Department or Hospital-Based Clinics (POS: 21, 22, 23)

In a hospital inpatient, outpatient or ER setting Physician Assistants and Nurse Practitioners may participate in a shared visit with a physician.  For billing purposes, this is considered a “Shared/Split visit”.

Physician Assistants and Nurse Practitioners may participate in new or established patient Evaluation and Management (E&M) visits where the supervising physician and NPP from the same group practice both provide services to the patient.  From the same group practice means that both providers must be within the same USC clinical department.

The following criteria must be met in order to bill a Shared/Split Visit:

  1. Shared/Split Visits are only applicable in the hospital-based setting (hospital inpatient, outpatient, emergency department or hospital based clinic (1206D clinic)).
  2. Billing a shared/split visit requires documentation from both providers to support the medical necessity and involvement of each in the patient’s care.
  3. Each provides a portion of the face-to-face E&M service on the same day and each must independently and personally document their own portion of the encounter with the patient.
  4. If the physician does not see the patient face-to-face, the service cannot be billed under the physician’s name.  In these cases, the NPP may bill for his or her personally provided service using the NPP’s own National Provider Identifier (NPI).
  5. Critical Care services can never be billed as a shared/split service between a physician and NPP.
  6. Procedures (major or minor) can never be billed as a shared/split service between a physician and NPP.  Procedures must be billed by the provider of service.
  7. The visit may be billed under the NPP or physician (not both) using the combined documentation of services by both providers (NPP & MD) to support the level of E/M billing.
  8. Shared/split visits are only billed when services are provided and documented consistent with and required by CMS, third party Payers, and/or licensing/accrediting agencies.
  9. The NPP services may not be included in the Hospital Cost Report.

If the required Shared/Split requirements, as outlined above, are not met; the service must be billed under the NPP’s own provider number.

V.  Billing Requirements for NPP Services In An Office Setting (POS: 11)

In an office setting, providers have two options to bill for Physician Assistant and Nurse Practitioner services commonly known as Non Physician Practitioners (NPP).

Billing for NPP services under the NPP’s own National Provider Identifier (NPI).

  1. Qualified NPPs may provide services without direct physician supervision and bill independently for these services (the physician must be available by phone to meet General Supervision requirements).
  2. For Medicare patients, the NPP must enroll in Medicare.
  3. Medicare policies must be followed when submitting bills for reimbursement, which in many instances are the policies followed by third party payers.  However some payers may adopt their own policies and procedures that may have billing limitations for NPP services. The billing office must keep the payors written instructions on file and provide the billing instructions to the Office of Culture, Ethics and Compliance as requested.
  4. Some payer’s reimbursement of independent NPP services are paid at 85% of the physician fee schedule.

Billing for NPP services as an “Incident-to” service under the physician’s provider number.

  1. Services provided and billed incident-to must be provided in an office setting (this does not include 1206D hospital-based clinics).
  2. The patient must be an established patient of the physician who has initiated the patient’s plan of care.
  3. The physician must be present in the office suite, during the time that the patient is seen and immediately available in order to provide assistance and direction throughout the time the qualified practitioner is performing services.
  4. The physician must remain actively involved in the patient’s care and must periodically see the patient for the ongoing disease or illness.  The billing physician does not need to see the patient each time that incident-to services are provided.  However, the billing physician must perform the initial service and subsequent services with a frequency that reflects the physician’s active participation and management of the course of treatment.
  5. Billing must be done under the billing number of the physician who is actually “on site” providing supervisory services within a collaborative agreement rather than the physician who initiated and monitors the care of the patient.
  6. The direct supervision standard must be met each time an incident-to service is provided.  The services need not be supervised by the ordering physician; another physician in the clinic may provide direct supervision that is considered a collaborating group physician.
  7. Incident to rules do not apply if there is a new illness or problem for which the physician has not previously seen the patient and there is not an established plan of care.
  8. The qualified practitioner must be acting under the supervision of a physician and must be an employee, leased employee, or independent contractor of the physician, or of the legal entity that employs or contracts with the physician and cannot be a hospital employed NPP.
  9. Reimbursement for “incident to” services allows the office to receive 100% of the physician fee schedule for services rendered by the NPP.  Notably, under Medicare, to bill “incident to” the Nurse Practitioner services must be furnished as an integral-incidental part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness commonly furnished in the office.
  10. Incident-to billing is not permitted in hospital inpatient, hospital outpatient, emergency department and hospital-based clinics (1206D), skilled nursing facilities, or in the home.

Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Report & Response at (213) 740-2500 or (800) 348-7454.