Medicare Billing Regulations for Nonphysician Providers Vary by State, Facility

Nurse practitioners (NPs) and physician assistants (PAs), referred to as nonphysician providers (NPPs) in billing policy, provide many different services in the hospital setting. Roles include:

• Rounding independently and following patients of varying acuity with physician supervision. The NPP may ask the physician to see the patient, as necessary, if a change in the patient’s condition arises and warrants physician evaluation.
• Providing prompt consultative
• services when the physician is not
• readily available.
• Rounding alongside the physician and expediting the work of admission services through a combined effort.

Hospitalist programs may elect one model over another, or utilize NPPs according to existing need and shifting census. Employers must be aware of state and federal regulations, facility-imposed standards of care, and billing requirements surrounding NPP services.

Medicare Enrollment and Billing Eligibility

Certified PAs and NPs may provide covered services to Medicare beneficiaries in accordance with their state scope of practice under state law and corresponding supervision/collaboration requirements. They can submit claims for these services, providing they meet enrollment qualifications.¹

PAs must have:

• Graduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant (or its predecessor agencies, the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and the Committee on Allied Health Education and Accreditation (CAHEA); or
• Passed the national certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA); and
• A license as a PA in the practicing state.

NPs must:

• Be a registered nurse who is authorized and licensed by the state to practice as a nurse practitioner by Dec. 31, 2000; or
• After Jan. 1, 2001, be a registered nurse who is authorized and licensed by the state to practice as an NP and be certified by a recognized national certifying body that has established standards for NPs (e.g. American Academy of Nurse Practitioners, American Nurses Credentialing Center, AACN Certification Corp., or National Board on Certification of Hospice and Palliative Nurses); and
• Possess a master’s degree in nursing.

Independent Billing

NPPs can see patients in any setting without the presence of a physician. The physician is not required to see the patient but must be available by phone or beeper in accordance with supervisory/collaborative guidelines. Physician cosignature is not required unless mandated by state law or the facility.

NPPs document and report their services according to the Centers for Medicare & Medicaid Services (CMS) Documentation Guidelines (available at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html). The NPP should be listed as the rendering provider on the claim form. Currently, insurance programs Medicare and Aetna Inc. consistently enroll and recognize NPPs as billing providers and reimburse these services at 85% of the allowable physician rate.²

Shared/Split Billing

When two providers (a physician and NPP) from the same group (direct employment or a lease arrangement contractually linking the providers) perform a service for the same patient on the same calendar day, CMS allows the combined services to be reported under a single provider’s name.

Allowable services. NPPs are only limited by the state scope of practice under state law, and the facility rules in which the NPPs practice. Services must be performed under the appropriate level of supervision or collaboration. Medicare reimburses reasonable and necessary services not otherwise excluded from coverage.

However, shared/split rules restrict the services reported under this billing model, recognizing only evaluation and management (E/M) services (and not procedures) provided in the ED, outpatient hospital clinics, or inpatient hospital (i.e. facility-based services). Shared/split rules do not involve all types of E/M services. For hospitalist programs, critical-care services (99291-99292) are excluded.³

Physician requirement. Shared/split rules require a face-to-face patient encounter by each provider on the same calendar day. There are no billing mandates requiring the NPP to see the patient before the physician does, although practice style might govern this decision.⁴ CMS does not specify the extent of provider involvement, but it could be established by local Medicare contractor requirements. Some contractors reference physician participation as a “substantive” service without further elaboration on specific parameters. Therefore, the physician determines the critical or key portion of his/her personal service. Minimalistic documentation can be problematic for quality or medicolegal aspects of patient care, and physicians might benefit from a more detailed notation of participation.