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In today’s busy medical practice, many rheumatologists are utilizing the services of nonphysician healthcare professionals such as nurse practitioners (NPs), physician assistants (PAs), clinical nurse specialists, certified nurse midwives, occupational therapists, and medical technologists. Rheumatology practices typically employ the services of NPs and PAs to assist with the overall patient flow. Having an NP or PA can be a great time saver and a revenue booster to rheumatology practices because this will create time to accept new patients. But, as with all things concerning coding and billing, there are certain guidelines that practices must adhere to when billing for the services of NPs and PAs, mainly when using the Medicare payor system.

Medicare allows physician practices to bill for the services of nonphysician providers, and these services are known as “incident-to.”   The Medicare benefit policy manual defines incident-to as “services furnished as an integral although incidental part of a physician’s personal professional service.” Nonphysician providers can bill incident-to services under the supervising physician’s name and national provider identifier number for reimbursement at 100% of the Medicare fee schedule.

In order for a nonphysician provider to bill incident-to for Medicare patients, these specific guidelines must be followed:

• The service must be performed in the physician’s office;
• The physician must be in the office suite at the time of the service;
• The nonphysician provider can only see established patients with established diagnoses; and
• The service must be in the scope of practice of the nonphysician provider.

If the above rules are not met, the nonphysician provider can still perform the service but would not be reimbursed as incident-to. The service would have to be billed under the nonphysician provider’s National Provider Identifier (NPI) number and reimbursed at 85% of the Medicare fee schedule.

As demonstrated above, there are specific criteria that must be met to employ a nonphysician provider. Here are some answers to frequently asked questions about using the services of NPs and PAs.

• Can a nonphysician provider see a patient, new or established, if there is no physician on site?
  • Yes, the services would have to be billed under the nonphysician provider’s NPI number, and the services would be reimbursed at 85% of the Medicare fee schedule.
• Can a nonphysician provider see a patient that has private insurance?
  • Each private insurance carrier will have its own specific guidelines on whether it would reimburse services performed by nonphysician providers. Physician practices should call to verify if services delivered by a nonphysician provider are covered under the patient’s policy.
• What happens if an established patients presents with a new problem during the visit with a nonphysician provider?
  • Either the visit can continue and it will have to be billed out under the nonphysician provider’s provider number; or
  • The visit must be suspended and the physician has to take over the visit. The physician must take the patient history of present illness, perform the exam, and make his or her own medical assessment.
    • It is not permissible to have the physician only read over the NP’s notes and make a medical decision on the nonphysician provider’s findings. This is considered to be a shared or split visit.

The partnership of physicians and nonphysician providers can bring successful financial benefits to rheumatology practices if the guidelines are followed. Remember, the rules for nonphysician providers are very specific for Medicare carriers but practices will have to contact private carriers for their guidelines for these types of providers. Nonphysician providers can be a great economic asset to a rheumatology practice if all the coding and billing guidelines are followed.