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Medical Billing Guidelines for Non-Physician Providers (NPPs)

July 20, 2017

Billing Guidelines for Non-Physician Providers (NPPs).jpg

Adding some non-physician providers (NPPs) to your practice is a great way to reduce costs while increasing patient satisfaction. Because they are not doctors, they will be less of a cash draw on your income. However, they will still provide excellent care and services to help curate and satisfy new patients. However, billing guidelines for non-physician providers can get a little bit tricky, as each insurance provider and state has its own regulations when it comes to NPP licensing and billing. Here’s some information to make your billing process go as smooth as possible.

Who Qualifies as an NPP?

Generally, the two types of NPPs are physician assistants (PAs) and advanced practice nurses (APNs). APNs can further be broken down into nurse practitioners, certified registed nurse anesthetists, certified nurse-midwives, and clinical nurse specialists. After these professionals provide services, there are two main ways you can bill for them. The first is to use “incident to” billing that will be listed under the head physician’s nation provider identifier (NPI). To qualify for this, the services must have been directly supervised by a physician.

The other method is using the NPPs own NPI for billing. This is often easier for many offices, as there’s less paperwork involved. However, the practice will earn slightly less, as PAs and APNs generally only qualify for 85 percent of the Medicare Physician Fee Schedule. 

Qualifications for Individual NPI Billing

However, if you want to use the NPP’s unique NPI for billing, you’ll need to make sure a few conditions are met. These include:

  • The local state allows the NPP to perform services
  • The services would be considered physicians’ services if rendered by a physician
  • The services are not excluded from coverage by law
  • The NPP was under the supervision of a physician

If these conditions are not met, Medicare or private insurance companies may deny your claim. NPPs will also have to become enrolled in Medicare by filling out the CMS-855l application. Private payers may also have their own credentialing system, so be sure to check with insurance companies before trying to bill for NPP services. If they will not pay for NPP services billed individually, they may have to be added under the physician’s NPI instead.

Qualifications for “Incident to” Billing

With “incident to” billing, it’s imperative that a doctor is present while the NPP is performing services. They don’t have to be watching directly, but they must be in the same office suite. What’s more, the services have to be a part of the patient’s normal course of treatment. This means that the doctor will have already diagnosed the patient, performed an initial service, and will continue to stay active in the patient’s care. 

If there’s a scenario where both the physician and the NPP provided joint services, then the visit should be billed “incident to.” 

What Services Can NPPs Provide?

Not every part of an NPP patient visit will be covered by insurance. Here’s a few common things that NPPs can do that will be covered:

  • Provide prescriptions
  • Coordinate referrals
  • Collect the patient’s medical history
  • Perform a physical exam
  • Order lab tests
  • Diagnose and treat diseases
  • Promote a healthy lifestyle

In addition to these services, NPPs can typically practice in the following locations:

  • Doctor’s office
  • Clinics
  • Hospital
  • Emergency department
  • Home services
  • Skilled nursing facility
  • Rest home
  • Residential substance abuse facilities

As you can see, the biggest choice you’ll have to make when billing NPP services is if you want it to be “incident to” or individualized. If you need any more help sorting our your billing issues, don’t hesitate to contact M-Scribe Technologies, LLC. We can provide a free analysis of your practice if you call us at 770-666-0470 or email


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