NPP (Non-Physician Providers) Billing Practices

In addition to the general billing and coding policies addressed in the Billing and Coding sections of this Manual, the following policies may be applicable to services furnished by NPPs. There are three different ways that NPPs can receive reimbursement. These are direct billing of services, Incident to a physician’s service, and Shared/Split visit services with a physician.

Objective

To set forth the requirements for NPP billing for their services under the three models of reimbursement.

Policy

Direct Billing by Non Physician Providers (NPPs)

Professional services rendered by certain licensed non physician providers or NPPs may be billed directly to the Medicare program, provided that the services are within the NPP’s scope of practice, as defined by State law. NPP’s who are eligible for direct billing include, but are not necessarily limited to, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists and Certified Nurse Midwives. In contrast, auxiliary personnel, such as most licensed and registered nurses and most technicians’, are not eligible for direct billing. NPP’s must be enrolled and receive their own provider numbers in order to directly bill services.

Reimbursement for Direct Billing of Services

Payment for NPP’s services is 80 percent of the actual charge, or 85 percent of the Medicare Physician’s Fee Schedule amount. NPPs may be employees or independent contractors of a physician or physician group practice, for the physician or group practice to bill for their services. PAs, may not bill their services directly to Medicare.

Incident to Billing by Non-Physician Providers (NPPs)

Under certain circumstances, services furnished by NPPs may be billed under a physician’s provider number as “incident to” the physician’s services. To be covered as “incident to” the services of a physician, the services must be:

An integral, although incidental, part of the physician’s professional service;
Commonly rendered without charge or included within a physician’s bill;
Of a type that are commonly furnished in a physician’s office or clinic; and
Furnished under the physician’s direct supervision. Direct supervision requires the physician to be present within the office suite and immediately available to furnish assistance and direction throughout the service. The physician need not be present in the room with the patient and NPP during the service, but must be in the office suite and immediately available.

For a service furnished by an NPP to be covered as incident to the services of a physician, there must have been an initial first service, a direct, personal, professional service, furnished by the physician to begin the course of treatment of which the service being performed by the NPP 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.

Services must be performed by an employee, leased employee, or independent contractor of the physician or an employee of the entity that employs the physician (thus, Columbia employed NPPs can provide “incident to” services for Columbia-employed faculty physicians).

Physicians are not required to countersign clinical notes entered by NPPs for claims submitted under the “incident to” provision for reimbursement reasons, but may be asked to do so for quality of care considerations. Documentation should contain evidence that the supervising physician was actively involved in the care of the patient and was present and available during the visit.

Reimbursement for Incident to Billing

Services billed as incident to are billed under the Physician’s name and paid at 100% of the Medicare fee schedule.

Split or Shared E/M guidelines

On January 1, 2023 new Medicare evaluation and management (E/M) guidelines are now in effect regarding split or shared services. The CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 12, section 30.6.18 includes a detailed breakdown of the new split or shared guidelines. This article summarizes the new Medicare E/M guidelines for split or shared E/M services effective in 2022.

Definition of Split or Shared Visit

A split or shared visit is an E/M visit in the facility setting that is performed in part by both a physician and a nonphysician practitioner (NPP) who are in the same group, in accordance with applicable law and regulations such that the service could be billed by either the physician or NPP if furnished independently by only one of them. Payment is made to the practitioner who performs the substantive portion of the visit.

Facility setting means an institutional setting in which payment for services and supplies furnished incident to a physician or practitioner’s professional services is prohibited under Medicare regulations.

Definition of substantive portion

Beginning January 1, 2024, substantive portion means more than half of the total time spent by the physician and NPP performing the split or shared visit.

During the transitional years, 2022 and 2023, except for critical care visits*, the substantive portion can be one of the three key E/M visit components (history, exam, or medical decision-making [MDM]), or more than half of the total time spent by the physician and NPP performing the split or shared visit. In other words, for calendar year 2022 and 2023, the practitioner who spends more than half of the total time, or performs the history, exam, or MDM can be considered to have performed the substantive portion and can bill for the split or shared E/M visit.

When one of the three key components is used as the substantive portion in 2022 and 2023, the practitioner who bills the visit must perform that component in its entirety to bill.

*For critical care visits, starting for services furnished in CY 2022, the substantive portion will be more than half of the total time.

Examples of Shared Visits

If the NPP first spent 10 minutes with the patient and the physician then spent another 15 minutes, their individual time spent would be summed to equal a total of 25 minutes. The physician would bill for this visit since they spent more than half of the total time (15 of 25 total minutes). If, in the same situation, the physician and NPP met together for five additional minutes (beyond the 25 minutes) to discuss the patient’s treatment plan, that overlapping time could only be counted once for purposes of establishing total time and who provided the substantive portion of the visit. The total time would be 30 minutes, and the physician would bill for the visit since they spent more than half of the total time (20 of 30 total minutes).

To bill as a split or shared subsequent hospital service, the billing practitioner reports CPT code 99232 if basing the coding on time. For calendar year 2022, if not using time, bill CPT codes 99231–99233 as meets the key component level on which the coding is based – the billing practitioner must perform of one of the three key E/M visit components of history, exam or medical decision making.

Modifier -FS (split/ shared E/M visit) must be appended to the E/M CPT code on the claim.

Note: The modifier identified by CPT for purposes of reporting partial services (modifier -52 [reduced services]) cannot be used to report partial E/M visits, including any partial services furnished as split or shared visits. Medicare does not pay for partial E/M visits.

Other Non-physician Providers

For practice information on other providers such as Certified Registered Nurse Anesthetists and Anesthesiologist Assistants, Nurse Specialists, please see this Advanced Practice Nonphysician Practitioners | CMS detailing NPP coverage from CMS.

Office for Billing Compliance
Policy#: 10027
Original Date of Issue: 1996
Revised: 3/22/2023
Reviewed: 3/1/2024