There is always confusion in appropriate roles and billing for non-physician practitioners (NPPs) such as nurse practitioners and physician assistants. Non-physician practitioner is the term CMS uses for these individuals, while other payers and organizations may refer to them as advanced practice providers, mid-level providers, or physician extenders. Nurse practitioners may also be called advanced practice nurses or other terms. The physician assistant professional organization recently voted to change their title to “Physician Associate,” although CMS does not recognize that term.

My history in working with these providers goes back to 1996, before they had billing rights for Medicare. I was Reimbursement Manager of a multi-specialty practice made up of 28 physicians and 14 nurse practitioners and physician assistants. I had the “pleasure” of realizing that we were billing all their services incorrectly and making the corrections in our processes and billing.

As coders and billers, helping practices maximize the role of these providers and ensuring they are paid appropriately for NPP services requires an understanding of the unique requirements that apply. Here are two essential regulations to know that pertain to billing for NPP services:

Incident-to

Incident-to is the first CMS doctrine to affect NPPs. It is a broad Medicare regulation that allows a physician to bill for services not personally performed but which are part of the physician’s overall care of the patient. There are specific requirements such as no new patients and no new problems, physician presence in the office suite, and employment relationship.

Incident-to is only applicable in the office setting, place of service 11 on CMS-1500 claims.

Split-shared

Split-shared was CMS’s attempt to extend some sort of working relationship between physicians and NPPs into the hospital setting. CMS made changes to split-shared billing guidelines in 2022 and 2023, and hopefully for the last time in 2024.

In order to bill services under the physician, the documentation must indicate that the physician performed the substantive portion of services and took responsibility for the management of the problems addressed. There are many questions about what this looks like in a real patient setting.

Here’s a bit more history: I had the pleasure of speaking personally with Kathleen Scally, the HCFA official (Yes, it was HCFA back then!) who wrote the original split-shared regulation. She attended a session I taught at an NPP billing conference on incident-to and split-shared billing. An NPP herself, she was trying to make a way to bill for services in the collaborative way they were already being performed. It was a delightful conversation, but the whole experience was almost as stressful as my first time teaching ICD-10-CM in front of Lynn Kuehn!

A Final Word on Non-physician Practitioners

While Non-Physician Practitioners are an increasingly important part of the care team in many organizations, there are concerns with the qualifications and licensure of NPPs. There are differences between states as to what services these individuals can legally perform. And although CMS applies the same payment regulations, nurse practitioners and physician assistants have different education and training and different scopes of practice.

The physician shortage in the US plays a major role in encouraging physician practices and hospitals to employ NPPs, but there are many considerations in determining appropriate roles and compliant billing.