The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.
Billing for Services Provided by Non-Physician Practitioners
With ever-increasing pressures on medical practices, I am seeing an increased reliance on non-physician practitioners (NPP) in providing care. In particular, nurse practitioners (NP) and physician assistants (PA) are being added to practices at an increasing rate. This is in part due to enactment of the Balanced Budget Act of 1997 (BBA). The BBA removed payment restrictions previously in place for Medicare Part B reimbursement of services provided by NPPs. A steady increase in the number of NPs and PAs in both physician offices and other patient care settings has continued. My personal experience has seen the largest increase of NPPs occurring over the last six to eight years.
Following enactment of the BBA and the resulting changes in reimbursement guidelines for NPPs, a disconnect between correct billing practices and those actually used for services provided by NPPs existed. Although rules for utilizing an NPP and billing under a physician existed, they tended not to be followed. Many insurers followed Medicare guidelines for services billed under the “split shared” and “incident to” concepts. The claims submitted simply showed services were provided by a physician even though they were provided by an NPP. In the event that an audit was performed, the signature on the office note was often presumed to be that of a physician and was not recognized by an auditor as that of one belonging to an NPP.
As time passed, providers were paid for a variety of services provided by their NPPs that were billed under their UPIN or NPI. The result was a false sense of security that correct documentation was in the chart and that billing was being done correctly. Unfortunately, the differing rules for “split shared” and “incident to” billing also became blurred. The pervasive belief that “because we have always done it this way” became engrained and further increased the risk of improper billing.
The Office of Inspector General (OIG) has made proper billing of NPP services a top priority over the past several years. As a result, over just the last few months, I have seen a significant increase in practices “self-disclosing” that they have improperly billed for NPP services. In January alone, two cases of self-disclosure regarding NPP services accounted for almost $1.5 million in penalties. (Office of Inspector General https://oig.hhs.gov/fraud/enforcement/cmp/psds.asp).
As your practice hires or looks to hire NPPs, make sure everyone knows the rules of documentation and billing. Make the “old habits” new again by ensuring your billing practices are current and compliant.