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Answers to Compliance and Medical Coding Questions.
  1. Sandeep Posted 4 month(s) agoRelated Topics

    Can we bill claims under provider when the services are provided by Nurse practitioner and provider is physically present for a short period of time and not present for complete encounter and reads NP's report and approves it for hospital services. Does the medical record needs to be co-signed by both?

  2. SuperCoder Posted 4 month(s) ago

    As per guidelines, NP’s generally can bill in two ways: independently and “incident-to”. 

    When billing “incident-to”, the following points can be considered:

    The patient may be scheduled under the physician or NP, but the bill is submitted using the physician’s NPI number.

    There must have been a direct, professional service furnished by the physician to initiate the course of treatment of which the service being performed by the NP is an incidental part.

    The answer regarding physician presence depends upon the state laws where the services are provided and the insurer.

    According to CMS, direct supervision in the office setting means the physician must be present in the office suite and immediately available and able to provide assistance and direction throughout the time the service is performed. Direct supervision does not mean that the physician must be present in the same room with the patient. 

    For more information, please see the information under “Coverage Criteria for NPs” in following link:

    https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Medicare-Information-for-APRNs-AAs-PAs-Booklet-ICN-901623.pdf

    Thank you.

  3. Sandeep Posted 4 month(s) ago

    Hello, Your answer is specific to office. Our query is related to hospital. Please provide answer specific to hospital setting.

  4. SuperCoder Posted 4 month(s) ago

    Hi

    As you rightly mentioned, the incident-to billing is not allowed in a hospital setting.

    Please find below, some general rules for NP billing in a hospital setting. However, they may alter depending upon the specific state, insurance carrier, etc. Therefore, please correlate the information with the specific details of the case that you are referring to.

    In a hospital, the services performed by the NP are to be billed under the NP's PIN number, provided no other provider has billed the service.

    For Medicare beneficiaries, there exists a shared/split billing policy. For example, a physician and NP from the same group practice may have provided a shared E/M service in a hospital inpatient/outpatient department or ED.

    • If the physician and NP share the services, and the physician has a face-to-face encounter with the patient, the service may be billed under either the physician's or the NP's PIN number.

    • If the physician has not provided any face-to-face services to the patient, but has only reviewed the patient’s medical record, then the service may only be billed under the NP's PIN number.

    For detailed information on shared/split services between the physician and the NP, please refer to the following link:

    https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R3315CP.pdf

    Hope this helps.

    Thank you.

About this Question

  • Posted by 69951 Sandeep, 4 month(s) ago. There are 4 posts. The latest reply is from SuperCoder.