Advanced practice providers (APPs) are integral members of many clinical care teams. Specific rules, however, apply for coding and billing for APP office visits. Terry Fletcher, CEO of Terry Fletcher Consulting, Inc., a health care coding and reimbursement consulting and auditing firm based in California, offers tips for avoiding common pitfalls.

Understand “incident-to” billing. In some circumstances, Medicare and other third-party payers allow APPs to code and bill under the supervising physician’s national provider identifier (NPI) for 100% reimbursement of services provided, rather than 85% if APPs were to bill under their own NPI. This is known as “incident-to” billing. Unfortunately, this approach can cause multiple problems and even trigger audits.

Briefly, Medicare criteria for incident-to billing include the following:

• APPs are defined as nurse practitioners (NPs), physician assistants (PAs), and sometimes clinical nurse specialists. “An RN is not considered an APP,” Fletcher says.
• The APP must provide services in an office, not a facility (e.g., emergency department).
• The APP must be under the direct supervision of a physician who is in the office suite and immediately available in person (not by phone, text, or page). “The doctor has to actually be practicing that day,” Fletcher emphasizes.
• The APP must follow a care plan established by the patient’s physician. If there are any changes to the plan—even a change in medication—incident-to billing cannot be used for that visit. “NPs can see new patients, but they cannot bill through incident-to,” Fletcher says, because a physician must initiate the care plan.
• The service should be billed under the supervising physician in the office, not necessarily the patient’s physician or the physician who developed the patient’s care plan.

Third-party payers may have their own guidelines. “I tell my clients to use the gold standard, which is Medicare,” Fletcher says. “If you are going to base everything you do on individual contracts, you should know what their policy is.”

Document the visit correctly. “Designate in the record that the appointment is an NP or PA visit,” Fletcher advises. The supervising physician should always countersign the record.

Check that APPs are not undercoding. “APPs tend to document better than physicians, but they tend to undercode, so sometimes that is a revenue loss,” Fletcher says.

Encourage APPs and coders to work together. “When they build a reciprocal relationship, it makes things go a lot easier,” Fletcher points out.

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