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Non-physician providers: What urologists need to know about billing


The NPP is an intriguing asset to a urology group and, as with other assets, requires monitoring from the business, clinical, and billing aspects. This article will provide some guidance and interpretation for reporting service requirements under the Medicare program.

Reporting of services for non-physician providers (NPPs) has received increased attention from both

Ray Painter, MDprovider groups and payers. These providers represent the fastest growing group within health care delivery and will continue to grow. Many urology groups have added or expanded the roles of the NPP in the past year.

The NPP is an intriguing asset to a urology group and, as with other assets, requires monitoring from the business, clinical, and billing aspects. This article will provide some guidance and interpretation for reporting service requirements under the Medicare program.


NPPs paid equally

Physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists (CNSs) are all referred to as non-physician practitioners under Medicare

Mark Painterguidelines. Even though the different provider types receive different amounts of training, Medicare treats them equally as far as payment for covered services. Each has a different specialty designation with the program:

  • PA: specialty code 97

  • NP: specialty code 50

  • CNS: specialty code 89.

Laws concerning licensure and scope of practice may differ from state to state, and Medicare rules require that each carrier recognize these state regulations as part of the Medicare payment program. As we see with respect to modifiers and other billing rules, private payers may have different rules on payment for PAs, NPs, and CNSs.

Again, for this article we will focus on Medicare, but keep private payer variation for NPPs on the list of required checks and balances from a billing prospective. The majority of directives related to NPP payment and policy are located in chapters 12 and 15 of the Medicare Carriers Manual for national considerations. For each state, NPP regulations are based on Medicare national guidelines but are clarified for each state in local coverage decisions and bulletins published by each Medicare Administrative Contractor.

PAs, NPs, and CNSs must have their own national provider identification (NPI) number in order take full advantage of the NPP scope of license; this process ties the NPP to the employer(s) with whom the NPP is contracted. In general, NPPs are paid for covered services at 85% of what a physician is paid under the Medicare Physician Fee Schedule for covered services when services are reported with the NPP NPI as the billing provider. In addition, payment may be made directly to an NP or CNS for their professional services when furnished in collaboration with a physician.

Appropriate NPI credentialing will need to be completed for the NPP similar to the credentialing process for physician providers for electronic and paper billing and payment processing. PECOS (Provider Enrollment, Chain and Ownership System), NPI, and clearinghouse forms and tools will need to be kept up in order to maintain status within the program. Similar to a physician provider, an NPP may contract with more than one entity but will have to be clearly credentialed and legally contracted for both clinical and administrative privileges with each group with whom the NPP is contracted.

The NPP employed by the private practice can also be used to assist at surgery, and the Medicare Carriers Manual (Chapter 12, Section 110.2) provides the following payment policy:

"The contractor shall pay covered NPP assistant-at-surgery 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. Since physicians are paid at 16 percent of the surgical payment amount under the Medicare Physician Fee Schedule for assistant-at-surgery services, the actual payment amount that PAs receive for assistant-at-surgery services is 13.6 percent of the amount paid to physicians. The AS modifier must be reported on the claim form when billing NPP assistant-at-surgery services." Note: Assistant at surgery rules noted in auacodingtoday.com will also apply to NPPs for each code.


‘Incident to’ billing

Every service provided in a physician’s office is billed as if the physician or an NPP provided that service. The services provided by employed auxiliary personnel such as nurses, technicians, and therapists, when furnished “incident to” the professional services of a physician, are billed under the physician or NPP NPI under the incident to rules. To qualify for incident to service billing, the service must be considered a service or supply that is normally provided by the provider and provided by the provider or under direct supervision of the provider.

The Medicare Carriers Manual (Chapter 15, Section 60.1) discusses direct supervision: “Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”

In addition to billing Medicare for an NPP under their NPI number, the physician may also be able to bill for NPP services using the physician’s NPI number under the “incident to” rules and receive payment of 100% of the physician payment amount instead of the 85% that is paid specifically for NPP services.

Services performed by NPPs include not only services ordinarily rendered by a physician’s office staff but also services ordinarily performed by the physician, such as minor surgery, reading x-rays, and other activities that involve evaluation or treatment of a patient’s condition. The NPP may also render evaluation and management service “incident to” if the appropriate circumstances are met.

In order for services of an NPP to be covered as incident to the services of a physician, the services must be an integral, although incidental, part of the physician’s personal professional services, and they must be performed under the physician’s direct supervision.

Therefore, according to the Medicare Benefit Policy Manual (Chapter 15, Section 60.2), “There must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the nonphysician practitioner is an incidental part, and there must be subsequent services by the physician of a frequency that reflects the physician’s continuing active participation in and management of the course of treatment. In addition, the physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary.”

This passage details the criteria for charging “incident to” for NPP services, but it also sets the stage for controversy. There are different interpretations of how detailed the physician’s active participation must be. On one end of the spectrum, if the physician has seen the patient and set up a "care plan" for that patient, then subsequent visits related to that problem could be charged incident to.

On the other end of the spectrum, one Medicare contractor has specifically stated that incident to by an NPP can only be charged if he/she adhered exactly to the physician’s plan of care as outlined in the chart. Specifically, the Medicare contractor stated that if the NPP changes the drug or dosage or provides service outside the exact care plan documented by the physician, the service provided by the NPP is not billable under “incident to” unless the physician is involved in the specific patient visit.

As with other types of providers, billing the services of an NPP “incident to” in a facility setting is not allowed. Depending upon state and hospital regulations, NPPs may be able to report services under their own NPI for services provided in a facility setting. If the physician and NPP both see the patient for an E&M service in a facility setting and the physician reconfirms the history, performs some physical examination, and reviews the plan of treatment, the visit may be reported under the physician NPI as a shared or split visit. This circumstance requires that both the physician and NPP are in direct patient contact at the facility on the same date.

We have discussed the appropriate billing for NPPs under the incident to rule with a number of Medicare contract medical directors. Our “best practices” interpretation is as follows:

  • The urologist outlines a specific “care plan” for that patient, which may be to follow a practice protocol on the treatment of that disease process. This should be detailed to the point that when the NPP sees the patient in follow-up, they can provide the appropriate treatment within the parameters set by the care plan and bill “incident to.” If the treatment for a particular visit requires a deviation from the care plan/protocol or is for a different process, then that visit should not be charged “incident to.”

  • NPPs should be specialized within the practice. Developing the expertise of the NPP as a part of the practice can expand the reach of the NPP to the patient and referral community. There are many areas in which the NPP can specialize, including incontinence, erectile dysfunction, interstitial cystitis, hospital rounds and assistant at surgery services, and emergency patient work-in or triage. We recommend focusing on areas of care that may require more time and take advantage of the skills of the NPP.

  • NPPs should be a part of the care treatment team. Even with specialized NPPs, the urologist(s) of the group should remain involved and guide care for the patients. Experience is a valuable asset, but the training of the NPP is not as rigorous as that required for a physician.

With the growing need for service and the limited number of physicians, a properly trained NPP is a valuable asset to the urology office. However, your office will need to take care that services are reported correctly and the NPP will need the appropriate clinical skills.UT

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