Crack the Codes: Practice Management & Coding Virtual Course-Workbook: PA and NP Billing Strategies for Both the Office and Hospital

Workbook: PA and NP Billing Strategies for Both the Office and Hospital

Pdf Summary

The document discusses Medicare guidelines for billing services provided by physician assistants (PA) and nurse practitioners (NP). It explains the concepts of "incident to" and split/shared billing, which are terms developed by Medicare for reporting non-physician provider services. The document also mentions that commercial insurance carriers may have their own rules for billing and may require additional modifiers.<br /><br />The guidelines state that "incident to" billing allows non-physician practitioners to provide services that are billed under the physician's National Provider Identification (NPI) number. These services are reimbursed at 100% of the Medicare Physician Fee Schedule (MPFS) allowable. The guidelines specify that the service must be provided to an established patient with an established problem, within the scope of the practitioner's state license, and under the direct personal supervision of the billing physician.<br /><br />On the other hand, direct billing allows the PA or NP to bill using their own NPI. The reimbursement rate for direct billing is 85% of the MPFS allowable. There are no restrictions on the type of patient seen or the level of physician supervision required.<br /><br />The document also explains the rules for split/shared billing, where both the physician and the PA/NP provide services to the patient on the same day. The substantive portion of the visit, which can be determined by time spent or by the provider who performed certain elements of the visit, determines who will bill for the service. The document includes exercises to illustrate how these rules are applied in different scenarios.<br /><br />Overall, the document provides an overview of the Medicare guidelines for billing PA and NP services, including information on "incident to" and split/shared billing. It clarifies the different rules and requirements for reimbursement and offers examples to illustrate their application.

Keywords

Medicare guidelines

billing services

physician assistants

nurse practitioners

incident to

split/shared billing

non-physician provider services

commercial insurance carriers

modifiers

reimbursement rate