Medicare Compliance & Reimbursement

Once you can clearly define non-physician practitioner (NPP), also referred to as or non-physician provider, in your practice or facility, you are well on the road to solving the incident-to billing riddle.

“Learning the ‘lingo’ in this area is a real challenge,” says Duane C. Abbey, Ph.D., president of Abbey & Abbey, Consultants, Inc. in Ames, Iowa, during his recent audio-conference “Effective Utilization of Non-Physician Practitioners,” sponsored by The Coding Institute affiliate AudioEducator.com. “You are going to have to take the time and trouble to step back and make sure that when you are reading a regulation or meeting with a group of folks or credentialing someone, that you understand exactly who they are and what they are, and that’s not always easy.”

Review the key words you need to know to help ensure proper incident-to billing, and effective use of NPPs to increase your patient base and bring in extra revenue.

Differentiate Practitioner From Provider From Physician

As noted above, the acronym NPP can refer to the terms non-physician provider or non-physician practitioner. So what is the difference?

“Well, one is a subset of the other,” Abbey explains. “A non-physician provider is simply a healthcare provider that provides healthcare services, that is not a physician.” Generally, when you are referring to non-physician practitioners, you are referring to non-physician healthcare providers who are allowed to bill professionally to Medicare, he adds.

If the common factor is that the NPP is not a physician, you then need to know who fits in the role of practitioner and who qualifies as a physician.

“Defining exactly what a physician is, is not exactly that straightforward,” Abbey cautions. He points to the Code of Professional Regulations, Title 42, Chapter IV, Subchapter B, Part 405 (42 CFR 405.400), for the definitions you should learn:

“Physician means a doctor of medicine; doctor of osteopathy; doctor of dental surgery or of dental medicine; doctor of podiatric medicine; or doctor of optometry who is legally authorized to practice medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, or optometry by the State in which he performs such function and who is acting within the scope of his license when he performs such functions.”

“Practitioner means a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, clinical psychologist, clinical social worker, registered dietitian or nutrition professional, who is currently legally authorized to practice in that capacity by each State in which he or she furnishes services to patients or clients.”

Resource: You can review these and other definitions in the CFR at www.ecfr.gov.

Reviewing these definitions brings about the question of what category podiatrists, chiropractors, physical therapists, occupational therapists, respiratory therapists, dieticians, medical nutrition professionals, and others fit in, Abbey says.

Check Various Scope of Practice and Qualifications

NPPs are growing in number because they are a lot less expensive to employ than are physicians. “I see a new type of NPP every time I travel,” Abbey comments. However, the scope of practice for an NPP is often different from that of a physician.

Before your practice hires a new NPP, you need to assess what the NPP can actually do in your practice, from both a scope of practice and a qualification perspective, at a variety of levels, as follows, Abbey says:

• National professional — Check with national professional organizations.
• National Medicare — Check the CFR, Federal Register, and appropriate manuals to see what the NPP can actually do.
• State law/rule — Check state statutes and administrative law.
• Employer/institution — Check the actual job descriptions, policies, and procedures your practice or facility has in place.
• Service area — Review the service activities and physician agreements in your practice to see what the NPP is allowed to perform.
• Personal — Finally, review the NPP’s personal competencies and training.

Questions: “The Medicare program recognizes a number of different non-physician practitioners for separate payment, but the list of NPPs in a given service area can be quite different,” Abbey explains. There are several questions you’ll need to find answers to, including:

• Which NPPs can provide telehealth services?
• Which NPPs can provide assistant at surgery?
• Which NPPs can set up private or independent practices?
• Which NPPs can bill through incident-to billing?

“Again, the biggest challenge we all have is terminology” Abbey says.

Best bet: Your practice needs to review all the information available, including federal regulations, state laws, and individual payer policies to ensure your NPP coding, billing, and reimbursement stay compliant and successful.