Many commercial payers have begun to require that services performed by mid-level practitioners [e.g., nurse practitioners (NPs) or physician assistants (PAs)] be billed under the National Provider Identifier (NPI) number of the practitioner and not that of the supervising physician. For example, we recently saw a bulletin from United Health Care stating that for its commercial plans, mid-level practitioner services cannot be billed under the physician’s NPI unless the practitioner is ineligible for an NPI. Since mid-level practitioner services are often paid less (e.g., 85% of the physician reimbursement rate), incorrectly billing these services under the physician’s NPI could be considered improper and even fraudulent billing.
Medicare still allows mid-level practitioner services to be billed under the physician’s NPI and paid at the higher physician rate but only if the “incident to” requirements are met. The two principal “incident to” requirements when billing for services of NPs or PAs are:
- The supervising physician whose NPI the services are billed under must be in the office and available to provide direct supervision when the mid-level practitioner is furnishing services.
- The mid-level practitioner can only see patients for existing problems, not new problems.
While NPs and PAs are permitted to see Medicare beneficiaries for new problems without direct supervision (if permitted under state law) those services must be billed under the NP’s or PA’s own NPI number – at the 85% reimbursement rate. Similarly, if an NP or PA is supervising auxiliary staff who are performing services “incident to” the NP’s or PAs service (and this supervision is allowed under their state license), those services must be billed under the NPI of the NP or PA.
Regardless of whether a service is billed “incident to” or under the NPI of the mid-level practitioner, the practitioner can sign their own notes, assuming it is allowed under state law. The supervising physician does not need to counter-sign; however, they should maintain documentation that they were present in the office to provide supervision if billing under the “incident to” rules.
For the duration of the Public Health Emergency, direct supervision under the “incident to” rules can be met virtually using interactive, real-time audio/visual communications technology.
Allergists who use mid-level practitioners in their practices should be alert to these changing rules. The Advocacy Council will continue to monitor and advise you on this issue – we have you covered.