Medical Coding Software And Billing Procedures for Nurse Practitioners and Physician Assistants

Physician Assistants (PAs) and Nurse Practitioners (NPs), often known as physician extenders or non-physician practitioners, are used in almost every medical practice (NPPs).

Understanding how to appropriately use medical coding software for NPP services is critical to having a profitable and efficient medical practice. Because regulations differ across insurance companies and states, both the physician and the NPP must remain up to date on practice guidelines and continuing developments.

Nurse Practitioners and Physician Assistants are becoming more common in most medical offices. Nurse practitioners (NPs) are nurses who have earned a Master's or Doctor of Nursing Practice degree (DNP). PAs are certified (PA-C) and often have a Master's Degree. Medical offices use these mid-level clinicians for a variety of reasons, including:

•        Lower salary expenditures (as compared to a physician)

•        Lower overhead costs

•        Increased patient volume

•        Lower insurance and liability costs

Medical billing and coding software provides three primary categories of reimbursement to these non-physician providers (NPPs).

Direct Pay

It is when an NPP has their own Provider Identification Number (PIN). The NPP (or practice) is reimbursed at 85 percent of the billable physician rate. It is critical that each of your mid-level providers obtain his or her own National Provider Identifier (NPI) and be credentialed with each payer to bill under his or her PIN number, if feasible, according to payer laws and regulations. Many payers, however, will not accredit NPPs. With the NPP certificate, practices can charge insurance companies directly when the "supervising physician" is either not present or has not provided any care or input into the patient's plan of care.

"Incident to"

This billing is a method of invoicing outpatient services delivered by a non-physician practitioner at a physician's office located in a different office or in an institution, or in a patient's home (NPP). In the course of billing, the physician bills and receives the full amount of Medicare's permitted payment. When an NPP sees a patient after the physician has done the initial service and established a Plan of Care or treatment plan, this type of billing is employed. There are special restrictions for this form of billing; the physician must be present on-site, in the suite rather than merely in the building, and offer direct supervision (the rules for home visits vary).

The medical billing solution physician can receive 100 percent of the Medicare Physician Fee Schedule (MPFS) instead of 85 percent of the MPFS for care performed by a qualified NPP by filing a claim "Incident to." New patients should be examined by the physician to establish the Plan of Care, which would be billed through the rendering physician. Following the initial visit, the NPP can offer follow-up treatment in accordance with the Plan of Services, charging for direct care as "Incident to." If changes to the plan of treatment are made, such as medication changes, the physician should meet the patient face to face to amend the initial plan of care; otherwise, the visit may not qualify for "Incident to" billing.

Because "Incident to" billing was designed by Medicare and not all commercial insurance carriers follow Medicare requirements, knowing payer restrictions surrounding "Incident-to" billing is critical before delivering patient treatment.

Expenses Split/Shared

Cloud billing software for shared/split services enables the practice to charge under the qualified physician rather than the NPP, which has a lower reimbursement rate. Billing for shared/split services provides for an additional 15% reimbursement as long as the conditions are satisfied.

In this form of billing, documentation is critical. To prove compensation under the split/share criteria that enable both parties to claim for services, each practitioner must properly document the care they delivered.

According to the Centers for Medicare and Medicaid Services (CMS), shared/split visits are permitted for services provided in the following settings:

•        Inpatient or outpatient hospitalization

•        Emergency department

•        Hospital observation

•        Hospital discharge

•        Office or clinic (where the "incident-to" criteria is satisfied)

Shared/divided visits are not permitted:

•        In a skilled nursing facility or nursing facility environment

•        For consulting services

•        For critical care services

•        For procedures

Conclusion

With changes in healthcare costs, patient care, and reimbursement, as well as physician shortages, there is a greater demand than ever for Nurse Practitioners and Physician Assistants. Individual payers must have a thorough awareness of the billing and reimbursement criteria. The standards for charting and documenting must be satisfied. To learn more about medical coding software, contact us at billrMD!