# Direct billing for Nurse Practitioners



## btrfliesfree123 (Jun 16, 2015)

Hi, I work for a Maternal and Fetal Medicine Office where we perform Ultrasounds, Genetic Counseling and Diabetes Management services.  I'm trying to get some more information on Direct billing for Nurse Practitioners when we see Diabetic patients.  I'm confused as to when we would use the Direct Billing guidelines.  My understanding of the guidelines is that the NP can bill for Consultations, New patient and Established patient visits without the direct supervision of a physician as long as the NP is credentialed with the Insurance company.  If the NP is not aware of what Insurance the patient has, how would she know that she can bill a consultation code?  We are running into problems where our NP is billing for Gestational Diabetes Consultations and she is not credentialed with the Ins Co so we can't bill for these.  Does anyone know how to bill for these services when performed by an NP?  Any help would be greatly appreciated!!


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## teresabug (Jun 16, 2015)

the office "should" be confirming insurance coverage days before the patient is even seen firstly. That way you will know what insurance coverage they have so that you can verify their bene's in advance. Your NP has to enroll with whatever insurance plan she expects to see patients for. Keep in mind that not all insurance payers recognize direct billing under a NP or PA. If your NP is an employee and works under the direct supervision of an MD or DO and the doctor is physically IN the office when the NP is seeing patients, you can bill "incident to". Meaning the Dr's name is reported on the claim not the NP's. Also... there are additional rules to this and these can be found on CMS' website and also the MAC website wpsmedicare.com


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## btrfliesfree123 (Jun 16, 2015)

We are verifying all insurances, but the physicians and NP's are not aware of what insurance the patient has.  We are billing incident-to, but can only bill for established patients.  Our NP is documenting for a Consultation on a new patient in which the physician does not see the patient first to start a treatment plan.  I'm guessing that we can only bill for this when she is actually credentialed with the Insurance Company.  In the cases where she isn't credentialed, how would we bill the Consultation?  We wouldn't be able to bill using the incident-to guidelines since the patient is new to our practice, not an established pt.


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## teresabug (Jun 16, 2015)

the pt demographics can be printed out on the encounter form so that the provider knows which ins the pt has. 
If the NP is seeing the patient where the provider has not set the plan of care, the visit does not fall under incident to and must be billed under the NP name. The suggestion is to have all new pt's see the Dr. to est a POC then f/u's to be scheduled with the NP. If the POC changes, the NP has to have to Dr. come into the room and treat the pt at that time. (i.e. change in meds for HTN, etc....)


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## btrfliesfree123 (Jun 16, 2015)

Thanks so much for your help!


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