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Billing for NP

Terry Posted Thu 16th of January, 2020 14:23:16 PM
When billing for a NP, does a modifier need to be used? If the NP sees a new patient, do carriers automatically recognize the NPI as a NP and reimburse at 85% or does a modifier need to be added?
SuperCoder Answered Fri 17th of January, 2020 02:44:44 AM

Hi Terry,


Please find below billing guidelines set forth by CMS for NPs


You may either:


  • Bill the Medicare Program directly for services using your National Provider Identifier (NPI) or Have an employer or contractor bill for your services using your NPI for reassigned payment
  • A supervising physician must bill under his or her NPI for services you furnish incident to the physician’s professional services
  • You must bill under your NPI for services furnished incident to your own professional services



Payment Guidelines for NPs


  • Payment is made only on assignment basis
  • Services are paid at 85% of the amount a physician is paid under the Medicare Physician Fee Schedule (PFS)
  • Payment is made directly to the NP for assistant-at-surgery services at 85% of 16% of the amount a physician is paid under the Medicare PFS for assistant-at-surgery services
  • Payment for services furnished incident to the services of a NP in a setting outside of a hospital is made to the NP at 85% of the amount a physician is paid under the Medicare PFS
  • When you bill directly for services furnished to hospital inpatients and outpatients, payment is unbundled and made to the NP


Please find attached, CMS link for more information:




Terry Posted Fri 17th of January, 2020 13:02:07 PM
On the claim form is a modifier required or added along with the NPI number to indicate a NP provided the services in an outpatient physicians office? For our office the billing provider is the Group name NPI. For example if the NP saw a patient in the physicians office would a modifier need to be used and the NP NPI used as rendering provider and the group NPI used as the billing provider? Thank-you
SuperCoder Answered Mon 20th of January, 2020 03:09:18 AM

Hi Terry,


For a group practice, rendering provider (one who has provided services to the patient) should mention his/her NPI in box 24J of HCFA 1500 form. Billing provider/ practice group Tax id should be mentioned in box 25 and billing provider NPI should be mentioned in box 33A of HCFA 1500 form.


You need not to append any modifier for services rendered by nurse Practioner.


By mentioning his/her NPI number in box 24J, it becomes clear that provider has served as a rendering provider for the patient in this claim.



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