The reimbursement amount for NPP services varies among payers. Many health plan contracts agree to pay for services billed under NPP provider numbers at 85 percent of the physician fee schedule. If you employ an NPP or anticipate hiring one, you might be able to negotiate a better reimbursement rate when you evaluate your next contract. Of course, whether your practice can do this is largely dependent on how much the insurance company wants your practice in its network. Sometimes this is easier for larger practices, but even smaller, rural practices can often negotiate if they are among the few family physicians in the area, for example.
Billing Medicare for NPPs' services can be confusing. Most of this confusion stems from Medicare's incident-to billing rules. (See “The Ins and Outs of ‘Incident-To’ Reimbursement,” FPM, November/December 2001, for more on incident-to billing.)
These rules apply to services provided by the NPP as an integral part of your care and allow you to bill for the services as if you, the physician, provided them. (Keep in mind that private payers that allow this type of billing may have different rules.) You can bill your NPP's services to Medicare under your provider number and be reimbursed at 100 percent of the Medicare fee schedule if the following criteria are met:
The physician sees the patient (at a previous visit) and initiates the plan of care that the NPP is carrying out. For example, the physician sees a patient with hypertension and asks the patient to follow up with the NPP.
The physician remains involved in the patient's care and documents this involvement in the patient's chart. For example, the physician's review of the NPP's note or discussions between the NPP and the physician may be documented, as well as periodic face-to-face time between the physician and the patient.
The NPP must be an employee of the physician or the group that employs the physician (leased or contracted employees are permitted).
The patient's physician (or another employed physician) must be in the office and immediately available. Medicare has made it clear that you may not bill the NPP service under the physician's provider number unless the physician is in the suite of offices and immediately available to provide backup. Telephone availability is not sufficient.
The service must be provided in the office. Incident-to services may not be billed in the emergency department, hospital or nursing home. Incident-to services are meant to cover usual and typical services provided in the office.
Unless the provider is a nurse practitioner, physician assistant, certified nurse midwife or clinical nurse specialist, the service can only be billed as 99211.
Practices should also obtain individual Medicare provider numbers for their NPPs so they have the option of billing Medicare directly for these services. Medicare pays 85 percent of the physician fee schedule in such cases. If there is not a physician in the office at the time the service is provided, the service must be billed under the NPP's provider number. New patient visits and consultations performed by the NPP must also be billed this way rather than incident-to because the incident-to rules require that the physician initiate the plan of care that the NPP carries out.
Billing for shared visits
In addition to understanding the requirements for incident-to billing, you should familiarize yourself with “shared visits,” a term created by the Centers for Medicare & Medicaid Services that applies only to Medicare patients. In general, incident-to services are for office-based services, and shared visits are for hospital services. Specifically, shared visits are evaluation and management (E/M) services provided to inpatients in a hospital or outpatients in the emergency department. These services are literally “shared” between you and an NPP. If both you and the NPP have a face-to-face encounter with the patient, the service can be billed under your provider number and is reimbursed at 100 percent of the physician fee schedule.
For a shared visit, you would typically provide and document some of the E/M service and the NPP would provide and document the majority of it. This allows your practice to use an NPP to provide hospital services while you return to the office to see patients. You do need to document this clearly to bill the service under your own provider number.
In the hospital setting, you must have a face-to-face encounter with the patient, documenting some part of the clinically relevant history, exam and medical decision making. It is not sufficient to simply note, “Seen and agree,” nor is it sufficient to simply countersign the note. You may see the patient before, after or at the same time the NPP sees the patient. The NPP will probably document the bulk of the note, but you must specifically document what you have personally done. Your practice can then select the level of service based on the combined elements and bill the encounter under your provider number.
Get paid for the work you do
Though the rules for shared visits and incident-to billing can be confusing, learning them will enable you and your practice to better evaluate the pros and cons of working with an NPP before you hire one. If you already work with an NPP, your practice will benefit from a thorough understanding of how to bill for the services NPPs perform; take the time to review your billing practices with these regulations in mind.