What Is a Nonphysician Practitioner (NPP)?

A nonphysician practitioner (NPP) is a healthcare provider who is not a physician but who practices in collaboration with or under the supervision of a physician. NPPs may bill payers directly, rather than billing under a physician, in certain circumstances. NPPs also may be known as mid-level practitioners, physician extenders, and advanced practice providers (APPs).

Who Qualifies as an NPP for Coding and Billing?

Examples of NPPs include:

• Physician assistants (PAs)

• Advanced practice registered nurses (APRNs)

  • Nurse practitioners (NPs)

  • Clinical nurse specialists (CNSs)

  • Certified nurse midwives (CNMs)

  • Certified registered nurse anesthetists (CRNAs)

This article includes specifics about PAs, NPs, and CNSs. Different rules may apply to other types of NPPs. Payers may define the term NPP specific to certain policies, as well.

A PA works under the supervision of one or more physicians, according to the Code of Federal Regulations (CFR), Title 42, Section 410.74, which applies to Medicare coverage. State law and scope of practice rules may detail the practice relationship required between physicians and PAs, including supervisory and collaborative practice requirements. For states that do not have these rules, the CFR provides this definition of physician supervision for PAs: “a process in which a physician assistant has a working relationship with one or more physicians to supervise the delivery of their health care services.” The practice must document the PA’s scope of practice and working relationships with supervising physicians as evidence of the physician supervision.

For Medicare to cover NP and CNS services, the NP or CNS must work “in collaboration with a physician.” CFR, Title 42, spells this out in Section 410.75 for NPs and in Section 410.76 for CNSs. Collaboration means the NP or CNS provides healthcare within their scope of practice with medical direction and appropriate supervision by one or more physicians. The law of the state where services are performed dictates the specific requirements. If there is not a state law governing collaboration, then the CFR states evidence of collaboration involves the NP or CNS documenting their scope of practice and indicating relationships with physicians to deal with issues outside the NPP’s scope of practice.

How NPP Coding and Billing Differs From Standard Practices for Physicians

The main differences between coding and billing practices for NPPs and physicians relate to scope of practice rules (which limit the services NPPs perform and therefore code) and the various approaches to billing NPP services, including billing the payer directly, billing a service as incident to the physician’s services, or billing a split/shared service. In other words, there are differences between NPP coding and billing and standard practices for physicians because NPPs may have more limitations than physicians regarding the services NPPs can perform and how they bill.

Practices and NPPs can ensure they are in compliance with coding and billing regulations and rules by following the same steps that ensure compliance for physician coding and billing, such as adhering to a program that applies the seven core elements of compliance, and also by being aware of the issues and resources discussed in the sections on medical coding and billing for NPPs below. Best practices to ensure security and privacy for patient data in NPP coding and billing are also similar to the work involved in coding and billing for physicians, centering around complying with HIPAA.

Best Practices for NPP Coding and Billing

To minimize errors and claim denials in NPP coding and billing, practices again can rely on the same best practices that they use for physicians, such as education of staff and auditing to discover and fix issues. But practices also need to consider items specific to NPPs based on payer and state rules. Healthcare organizations also may create their own stricter policies that NPPs, coders, and billers will need to be aware of to ensure compliance and consistency in reporting. Some of the major areas to watch for NPP coding and billing are described below.

Medical Coding for NPPs

NPPs report their professional services to third-party payers using the same medical codes as physicians, such as CPT^®, HCPCS Level II, and ICD-10-CM codes. However, scope of practice rules from a state, payer, or other source governing the NPP’s work may affect which services the NPP may provide and, consequently, report for payment. There also may be instances where the NPP’s participation requires use of specific codes or modifiers on the claim, such as modifier AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery.

Medical Billing for NPPs

The way an NPP service is performed and billed may affect reimbursement. To support accurate NPP billing, healthcare organizations should check for payer-specific policies. Three helpful sources for understanding Medicare’s NPP rules are the MLN Booklet Advanced Practice Registered Nurses, Anesthesiologist Assistants, and Physician Assistants; Medicare Benefit Policy Manual, Chapter 15; and Medicare Claims Processing Manual, Chapter 12. These resources offer information on three of the main approaches to billing Medicare for NPP services, described below.

Direct Billing by NPPs

Direct billing allows the NPP to bill a service using their national provider identifier (NPI). For Medicare services, the booklet states that NPs and CNSs may bill Medicare directly for services using their NPI or have an employer or contractor bill services using the NPP’s NPI for reassigned payment.

For PAs, their W-2 employer or 1099 independent contractor may bill using the PA’s NPI, with payment made to the employer or contractor. The 2022 Medicare Physician Fee Schedule (MPFS) proposed rule indicates this may change in 2022, with PAs being allowed to bill Medicare directly for their services. Once the 2022 MPFS final rule is published, PAs, their employers, and contractors should check to confirm whether PAs may bill Medicare directly.

When an NPP bills Medicare using their NPI, they typically get paid 85 percent of what a physician gets for the same code. That is because Medicare generally pays PAs, NPs, and CNSs at 80 percent of the lesser of the actual charge or 85 percent of physician payment under the MPFS.

Incident-To Billing by NPPs

Incident-to billing is a Medicare concept that other payers may adopt. A physician or other authorized practitioner (including PAs, NPs, and CNSs) may supervise certain other employees who provide services incident to the physician or other practitioner’s services. The supervising physician or other supervising practitioner then bills for that incident-to service using their NPI.

NPP services performed incident to a physician’s services are eligible for 100 percent reimbursement when billed under the supervising physician’s NPI, as opposed to the 85 percent payment services earn when billed under the NPP’s NPI. As noted above, NPPs also can be the supervising practitioner for auxiliary personnel like nurses and medical assistants, but, in that case, the reimbursement will be at the NPP rate rather than at the physician rate.

For Medicare to consider NPP services to be incident to physician services, the services must meet the requirements outlined in Medicare Benefit Policy Manual, Chapter 15, Section 60. Some of the rules are listed below.

Requirements for Medicare to Cover NPP Services Incident to the Services of a Physician in an Office or Clinic

• In a noninstitutional setting (all settings other than a hospital or skilled nursing facility), the incident-to services must be furnished as “an integral, although incidental,” part of the physician’s personal in-office services (Medicare Benefit Policy Manual, Chapter 15, Sections 60.1 and 60.2).

• The service must be commonly furnished in physician’s offices or clinics (Section 60.1.A).

• The service must be commonly rendered without charge or included in the physician’s bill (Section 60.1.A).

• The physician must have performed a direct, personal, professional service to initiate the course of treatment the NPP’s service is part of (Section 60.2).

• The physician must provide direct supervision of the NPP. The supervising physician does not have to be in the room at the same time as the NPP. However, the physician must be physically present within the suite and available if necessary (Section 60.2).

  • In a highly organized physician-directed clinic or group association, several physicians may share the responsibility of providing direct supervision. The supervising physician does not need to be the ordering physician (Section 60.3).

  • Certain services to homebound patients in medically underserved areas may require only general physician supervision, meaning the physician does not need to be at the patient’s residence but the physician does need to maintain overall supervision and control of the service (Section 60.4.A).

• There must be subsequent services by the physician frequent enough to show the physician continues to actively participate in and manage the course of treatment (Section 60.2).

• Medicare Administrative Contractors (MACs) must not apply incident-to requirements to services that have their own benefit category, such as diagnostic tests (Section 60.A).

What NPP services are considered incident to physician services? 

“Services performed by these nonphysician practitioners incident to a physician’s professional services include not only services ordinarily rendered by a physician’s office staff person (e.g., medical services such as taking blood pressures and temperatures, giving injections, and changing dressings) but also services ordinarily performed by the physician such as minor surgery, setting casts or simple fractures, reading x-rays, and other activities that involve evaluation or treatment of a patient’s condition,” according to Medicare Benefit Policy Manual, Chapter 15, Section 60.2.

Because incident-to rules require the physician to initiate the course of treatment, NPPs cannot bill certain evaluation and management (E/M) office visits as incident to the physician’s services:

• New patient visits

• Established patient visits where the patient has a new problem or condition

Split/Shared Billing by NPPs

A shared or split visit is one in which “a physician and other qualified health care professional(s) [QHPs] jointly provide the face-to-face and non-face-to-face work related to the visit,” according to CPT^® E/M guidelines.

This CPT^® definition relates more to medical coding than billing, instructing that when you use time to decide the code level for a split/shared visit, you sum the time the physician and other QHPs spend individually assessing and managing the patient on the encounter date. But when the physician and other QHPs meet or discuss the patient, you count that time only once (not per person) for code selection.

Payer definitions for split/shared visits may vary from the CPT^® definition. One important area to watch is that Medicare removed sections from its manual related to split/shared guidance in May 2021 and announced plans to publish new guidance in the future. Medicare will continue to cover split/shared services in the meantime. For coverage, the documentation must continue to meet medical necessity guidelines and any applicable statutory and regulatory requirements.

The 2022 MPFS proposed rule includes proposals for Medicare’s new split/shared visit rules. In its Fact Sheet, Medicare indicated the revision is necessary to provide better representation of current medicine practices due to the ever-changing role of NPPs and to have clearer conditions of payment to bill Medicare.

The proposals include defining “split (or shared) E/M visits,” in part, as E/M visits provided in the facility setting by both a physician and an NPP in the same group. The provider performing the substantive portion of the visit would bill for the visit. Substantive would mean more than half of the total time spent by the physician and NPP performing the visit. 

The proposed rule would allow providers to report split/shared for new patients, established patients, initial visits, subsequent visits, prolonged visits, critical care, and visits in skilled nursing facilities (SNFs) or nursing facilities. Medicare also proposes to require a modifier on the claim to ensure program integrity by identifying on the claim that the visit was split/shared. Documentation within the records would identify the two providers performing the visit. The provider performing the substantive portion of the visit would be required to sign and date the medical record, according to the proposed rule. 

Prior to the removal of the Medicare manual sections, split/shared billing was applicable to a service defined as “a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service,” according to Medicare Claims Processing Manual, Chapter 12, Section 30.6.13.H (in May 2021, Medicare changed the section to read “Left intentionally blank for future updates.”) The physician and NPP had to be in the same group practice or be employed by the same employer. Split/shared services could not be reported in SNFs or nursing facilities, and the concept also did not apply to critical care services.

For billing, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.B, previously indicated that the concepts of incident-to and split/shared overlapped. If a split/shared service was performed in the office setting and the service met incident-to requirements, the physician could bill the service under their NPI. If incident-to requirements were not met, the NPP billed the service under their NPI. (The May 2021 manual update replaced the prior language with “Left intentionally blank for future updates.”)

The same manual section previously explained that within the hospital setting (inpatient, on- or off-campus outpatient hospital, or emergency department), if a physician performed a face-to-face encounter during a visit shared with an NPP, either the physician or the NPP could bill the service. The documentation of both providers combined to support selection of one E/M code, even if the physician and NPP services occurred at different times of the day. If the physician did not see the patient face to face, such as when the physician reviewed the patient’s chart and discussed it with the NPP, then the NPP had to bill the service.

The takeaway is that split/shared services mean just that: The physician and the NPP are splitting and sharing the service performed, combining efforts to treat the patient. Physicians and NPPs should follow documentation best practices to ensure compliance with the rules for billing split/shared services, personally documenting their portions of the E/M visit in the patient’s medical record to support the combined code level reported to the payer. NPPs and the organizations they work with should review the 2022 MPFS final rule when it is available to be sure they comply with those official policies when reporting split/shared services to Medicare.

Types of Services NPPs Code and Bill

The types of services NPPs code and bill can vary for reasons such as their specialty, their certification, and their state laws and regulations regarding scope of practice. NPPs and their employers also should be aware of payer guidelines related to NPP coding and billing. For Medicare, the previously mentioned Medicare Claims Processing Manual and Medicare Benefit Policy Manual are good starting points for researching qualifications and billing guidelines for services provided by NPPs. The list below offers an overview of the types of services NPPs perform, based on the Medicare manuals. Keep in mind that supervision rules, qualification requirements, legal authorization by the state, and other factors may affect whether the NPP may provide a service and whether Medicare will cover it.

Examples of Services Medicare Allows NPPs to Perform

Medicare Claims Processing Manual, Chapter 12:

• Assistant-at-surgery services with modifier AS on the claim (Sections 110.2 and 120.1)

• E/M services (Section 30.6.1)

• Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) (Section 30.6.1.1)

• Examination and prescription for power mobility device (Section 30.6.15.4)

• Care plan oversight (Section 180)

• Telehealth services (Section 190.6.4)

• Primary care services (Section 230.1)

Medicare Benefit Policy Manual, Chapter 15:

• Consultation services (Section 30.C)

• Medical services such as taking blood pressure and temperature, giving injections, and changing dressings (Section 60.2)

• Minor surgery (Section 60.2)

• Setting casts or simple fractures (Section 60.2)

• Reading X-rays (Section 60.2)

• Diagnostic tests (Section 80), such as psychological and neuropsychological tests (Section 80.2) and audiology services (Section 80.3.A)

• Applying surgical dressings (Section 100)

• Providing, certifying, or supervising rehabilitation therapy services (Section 220.A)

• Ordering tests such as lab tests (Section 80.1), bone mass measurement (Section 80.5.4), and fecal-occult blood test (Section 280.2.2.A)

• Flexible sigmoidoscopy (Section 280.2.2.B)

• Certifying the need for diabetes self-management training (Section 300)

In the 2021 MPFS final rule, Medicare finalized a policy to allow NPs, CNS, PAs, CNMs, and CRNAs to supervise performance of diagnostic tests within their scope of practice and state law. The NPP also must follow the statutory requirements under Medicare regarding supervising and collaborating physicians.

Where Can You Find State Regulations for NPPs?

Because NPP practice varies by state, healthcare organizations need to know where to find applicable state regulations governing areas like signature authority, maintaining licensure, and scope of practice to ensure compliance.

Healthcare organizations should work with their compliance and legal teams and reference official regulations and state boards when creating policies regarding NPPs. Professional societies’ websites can be a starting point for finding these rules. For instance, the American Association of Nurse Practitioners (AANP) has a state-by-state listing to help guide NPs, as well as a map that quickly shows whether a state is a full practice, reduced practice, or restricted practice state. Full practice gives NPs scope to evaluate patients; diagnose, order, and interpret diagnostic tests; and start and manage treatments, which includes prescribing medications and controlled substances. Reduced practice limits NPs’ ability to engage in one or more elements of NP practice and requires the NP to have a regulated collaborative agreement with another healthcare provider. Alternatively, reduced practice may limit the setting of at least one element of NP practice. Restricted practice laws limit NPs’ ability to engage in one or more elements of NP practice and require supervision, delegation, or team management by another healthcare provider.

There are ongoing discussions among stakeholders, such as professional associations and state governments, to allow NPPs to hold one multistate license that allows the NPP to practice in participating states. An example is the APRN Compact. State boards of nursing adopted the APRN Compact on Aug. 12, 2020, but states must enact legislation for the compact to be implemented.

Aside from checking state-to-state scope of practice, NPPs also must consider payer differences, which may vary by location. Medicare rules do not necessarily impact private payer guidelines. Organizations also should not assume that Medicaid rules for NPPs are identical to Medicare. Healthcare organizations should check local state Medicaid sites and payer sites to keep abreast of guidelines. Creating a system that allows easy access to relevant state and payer policies is crucial for organizations to support best practices for NPP coding and billing as well as compliant use of NPP services.

Pros and Cons of Employing NPPs in Practices

NPP services play a vital role in revenue maximization for provider organizations when used correctly. Practices can save overhead costs because an NPP is typically paid a lower salary than a physician in the same practice. In addition to revenue growth, provider practices employing NPPs also may have higher employee satisfaction because spreading the workload allows for a better work/home balance for providers.

To reap the full benefits of employing NPPs, healthcare organizations should think carefully about which roles they assign to NPPs. For instance, NPPs, such as NPs, sometimes serve as scribes to physicians, but this often is not a good use of NPP time. When scribing for physicians, NPPs cannot provide their medical opinion or document any information in the record other than what the physician is dictating. The work of an NPP acting as a scribe cannot be combined with the treating physician’s work. Put another way, the NPP could be seeing a different patient during this time and generating revenue rather than acting as a scribe, which is a nonbillable service. Because of the restrictions on what scribes may do, there are also compliance issues to consider. The compliance team must watch and audit for NPP scribes who make the error of “improving” documentation to maximize revenue. If an office or hospital does use scribes, the entity should set a plan in place to audit, guide, and outline use of scribes according to the rules.

NPPs also may help a practice achieve higher patient satisfaction. For instance, patients may have faster access to care when scheduling to see an NPP rather than waiting to see a physician. NPP services also may provide greater access to care for patients who are disadvantaged or live in rural areas that have experienced an increase of closures for small facilities. NPPs can help provide care both by being present in the community and through telehealth.

Telehealth can provide a financial win and convenient option for both patients and provider practices by reducing transportation costs, patient absences from work, hospital readmission, unnecessary emergency department visits, and no-show visits, and improving overall patient outcomes. NPPs have licensure specifically within the state they practice in, but during the COVID-19 public health emergency individual states may have waivers allowing NPPs, as well as physicians, to provide telehealth services across state lines. Practices and providers should be cautious and enact a plan for staying up to date on applicable rules as there is a wide variation in telehealth rules state by state.