Nurse Practitioner and Physician Assistant Coding and Billing

2015 - 6 December - Quality Improvement
Scott P. Sherry, MS, PA-C, FCCM; Kathy Magdic, DNP, RN, ACNP-BC, FAANP
Two experts discuss nurse practitioner and physician assistant coding and billing.

Nurse practitioners (NPs) and physician assistants (PAs) characterize an increasing segment of healthcare professionals who provide care to patients in diverse settings.(1) NPs/PAs can safely and effectively provide care in the intensive care setting in a cost-effective manner.(1) As members of the critical care team, understanding the issues surrounding proper billing and coding for NP/PA care is important. This article will focus on shared visits, critical care, procedures, and surgical first assist.

The Balanced Budget Act of 1997 formally recognized NPs and PAs as healthcare providers. They are eligible to obtain their own provider numbers and submit bills under Medicare Part B for evaluation and management services (E/M) and procedures. An NP must be a registered nurse with a graduate degree who holds national certification and is legally authorized to practice in the state where the services are performed.  PA services are performed in collaboration with a physician and general supervision rules apply.  Services provided by the NP/PA must be within the scope of practice in the state where the NP/PA practices and must be medically necessary. Medicare will reimburse the NP/PA at 85% of the physician fee schedule rate.  Individual Centers for Medicare & Medicaid Services (CMS) contractors may have their own interpretation of CMS rules. Likewise, other payers may have different rules regarding NP/ PA provider status; therefore individual payers should be consulted for clarification.

Shared Visits
Under Medicare’s shared visit rules, E/M services properly documented by both a physician and the NP/PA may be billed under the physician’s number to obtain 100% reimbursement.  To bill a shared visit the service must be within the scope of practice of the NP/PA and may occur jointly or independently on the same calendar day. The E/M service must involve a face-to-face patient encounter that includes both the NP/PA and the physician. Documentation must clearly identify the NP/PA and physician involvement and include some portion of the history, physical examination, and/or medical decision making. Total documentation must support the level of service reported and may be billed under either the NP’s/PA’s or the physician’s provider number. If no face- to-face encounter occurred between the patient and the physician (even if the physician participated in the service by reviewing the patient’s medical record), the service must be billed solely under the NP’s/PA’s provider number, in which case the service will be reimbursed at 85%.(2) Importantly, a shared visit does not apply to critical care services.(2)

In addition to meeting the rules, certain employment relationship criteria between the NP/PA and physician must be met. These include that the NP/PA is a W-2 employee of the physician, group practice, or other entity that employs the physician or that the NP/PA is a contracted or leased employee of the physician, group practice or other entity that employs the physician.

Critical Care
NPs and PAs may bill for critical care time, and the code 99291 may be used by a single physician or a qualified NP/PA. Any care beyond 74 minutes is billed using the add-on code 99292, and the care can be provided by a physician or an NP/PA of the same group practice. CMS states “If a physician or qualified NPP (non-physician practitioner) within a group provides ‘staff coverage’ or ‘follow-up’ for each other after the first hour of critical care services was provided on the same calendar date by the previous group clinician (physician or qualified NPP), the subsequent visits by the ‘covering’ physician or qualified NPP in the group shall be billed using CPT critical care add-on code 99292.”(2) However, there are some regional interpretations still being discussed. Therefore, it is imperative that providers check with their regional carrier. 

Procedures done by NPs/PAs are billable and reimbursable by Medicare at 85% of the physician schedule. Like critical care codes, procedural codes may not be shared according to Medicare rules.(2) The NP/PA must be credentialed and privileged to perform the procedure and state rules apply. If the NP/PA performs the procedure it must be billed and reimbursed under their national provider identifier.

Surgical First Assist
NPs/PAs may provide surgical assistance in both teaching and nonteaching settings. Medicare reimbursement for surgical assisting services is 85% of the physician surgical assist fee. The physician surgical assist fee is 16% of the surgical fee, and reimbursement for the NP/PA would amount to 13.6% of the surgical fee. Reimbursement in nonteaching centers is straightforward. In teaching hospitals, additional criteria must be met. To ensure appropriate reimbursement for the NP/PA surgical assisting in teaching hospitals, it is important to follow applicable guidelines. Payment in these circumstances is made when any of the following criteria are met and documented:
1. The surgeon has a policy of never involving residents in the care of their patients. Generally applies to community surgical practices that do not utilize residents or provide surgical training.
2. No qualified resident is available. While the exact criterion for what constitutes a qualified resident is vague and may be left to the primary surgeon’s discretion, the general view is that if a medical training program is related to the surgical procedure being performed and a qualified resident is available, reimbursement is not provided to the NP/PA. There are instances where a qualified resident might not be available (e.g., the resident is involved in educational activities, off duty, or participating in another surgery). The degree of surgical complexity may also factor into the determination of what constitutes a qualified resident.
3. Exceptional circumstances. Multisystem trauma and other life-threatening cases such as emergent surgery may require additional assistants in surgery, and reimbursement for the NP/PA or additional surgeon may be appropriate. Exceptional circumstances should be well documented to justify reimbursement when other qualified residents are available.(2)

To process appropriate claims in teaching hospitals, additional documentation and certification are needed, and the modifier -82 should be added to the code in a case in which a qualified resident surgeon was not available. Carriers retain the certification for four years and review for appropriate payment and recovery is undertaken if warranted.

NPs and PAs play a vital role in the care of the acute and critically ill patient. It is imperative that NPs/PAs be familiar with all the rules and circumstances that are associated with any code used and understand billing and coding practices. Proper documentation is paramount for reimbursement.

References :
1. Kleinpell RM, Boyle WA, Buchman TG. Integrating Nurse Practitioners & Physician Assistants into the ICU. Mount Prospect, IL: Society of Critical Care Medicine; 2012.
2. Centers for Medicare & Medicaid Services (CMS). Medicare claims processing manual. Chapter 12: Physicians/nonphysician practitioners. CMS Web site. Rev. 3096, 10-17-14. Accessed September 26, 2015.