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Deborah Grider, CPC, CPC-P, CPC-I, COC, CPMA, CEMC, CCS-P, CDIP
The acronym NPP (nonphysician practitioner) is commonly used to describe a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). An NPP is not a registered nurse, certified scrub technician, certified first assistant, certified registered nurse assistant, or medical assistant; Medicare does not credential auxiliary personnel.
Let’s start off by identifying the three types of billing for the NPP.
Medicare defines “incident-to” as a service provided by an NPP but billed by the physician using the physician’s National Provider Identifier (NPI). Incident-to billing does not apply to the hospital setting (e.g., critical care, inpatient, outpatient hospital, provider-based clinic). Only established patients with established problems can be billed under incident-to. If the established patient encounters a new or worsening problem, the patient encounter cannot be reported as incident-to. Incident-to does not apply to consultations or new patients in the office setting.
The advantage of incident-to billing is that the practice is reimbursed 100% of the Medicare Physician Fee Schedule (MPFS) allowable. If the NPP bills directly to Medicare, with his/her name and NPI on the claim form, then the payment is reduced to 85% of the MPFS allowable—a 15% reduction).
These services must meet all of the following six incident-to criteria:
1. The course of treatment is initiated by the physician, and the physician involvement reflects continuing active participation in and management of care.