Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Billing for NPPs: “Incident to”, Split/Shared, and More

Healthcare reform, disgruntled physicians, and an aging population usually get the blame for current and expected physician shortages, not to mention to the rising costs of malpractice insurance and the doctors aging, themselves.

While medical schools are trying to do their part to funnel more doctors into the pipeline, the healthcare industry is beginning the necessary shift away from physician-only medical care and moving toward more non-physician providers (NPPs) to help fill in the gap.

In a recent article for Physicians Practice, Physician Shortage, Reform Lead to New Staffing Roles,” author Aubrey Westgate said that more and more providers are recruiting physician assistants (PAs) and nurse practitioners (NPs) to help manage their practices.

Citing a recent job report by healthcare recruiter HealtheCareers Network, Westgate said the number of physician job openings posted in the second quarter of 2012 remained flat while the number of NPP job postings rose by 16 percent for NPs and 10 percent for PAs.

As practices hire more NPPs, however, it becomes increasingly important that claims to insurance companies are filed correctly.

The Centers for Medicare and Medicaid Services (CMS) have two policies that apply to billing services for NPPs.


CMS’s “Incident To” policy covers services by an NPP in a physician’s office that are part of a patient’s normal course of treatment, during which a physician personally performed an initial service and remains actively involved in the course of treatment. The physician does not need to be physically present during the”incident to”service, but must be in the office suite and able to render immediate assistance if necessary. The patient record should document these essential requirements when billing”incident to”services under the physician’s credentials.

Further, the”incident to”services must be an integral part of the patient’s treatment course, commonly rendered without charge (included within the physician’s bill), of a type commonly furnished in the physician’s office or clinic, and an expense to the physician. NPPs providing the care must be directly supervised by the physician or another member of physician’s group under whom the services are billed.

If the “incident to” requirements are not met, the services must be billed to CMS under the NPPs credentials and paid at a reduced rate by Medicare.

Commercial payers often have less restrictive guidelines when billing NPP services under a physician’s credentials, particularly in these “incident to” scenarios. Anthem in Indiana, however, has a more restrictive policy.

Any provider assigned or eligible to be assigned an Anthem ID must have services billed out under his own NPI, and is not eligible in an “incident to” scenario. Additionally, only providers for whom Anthem does not ordinarily provide an ID if requested can submit claims in an “incident to” scenario.

In other words, “services rendered by any provider who is eligible, under Anthem policies, to directly submit claims to Anthem for reimbursement [including nurse practitioners and physician assistants], regardless of whether NPP has or has not applied for an NPI or whether an application for an NPI is pending” are not eligible for reimbursement as “incident to” services.

Services submitted under the NPI of an NPP are typically reimbursed at a reduced rate under the Anthem payment policy.


When an NPP is practicing in a hospital inpatient/outpatient setting or the emergency department, another CMS policy applies to evaluation and management services that are shared with a physician from the same group. Those services can be billed to Medicare under the physician’s credentials if the E/M visit is 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.

A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer.

If there is no face to face encounter between the physician and the patient, however, the service must be billed to Medicare under the NPPs credentials for reduced payment, regardless of whether the physician participated in the service by reviewing the medical record, discussing the patient with the NPP, or signing off on the medical record. Both “face-to-face” and “substantive portion” are critical for Medicare in recognizing the split/shared service.

WPS Medicare, Indiana’s Medicare Administrative Contractor (MAC), further requires that both the NPP and the physician each document the portion of the service that they provided. Standard phrases such “Patient seen” or “Agree with plan” signed by the physician do not constitute adequate physician documentation according to the WPS guidelines.

The Split/Shared concept does not apply to critical care services or procedures and may not be billed in a skilled nursing facility or a nursing facility.

As with “incident to” services, many commercial payers have even broader guidelines for when NPP split/shared services can be billed under the physician’s credentials. In email correspondence with an Anthem representative, she indicated that Anthem in Indiana follows the CMS guidelines for split/shared services, and an E/M shared by an NPP and a physician in which the physician has face-to-face contact with the patient can be billed out under the physician’s credentials.

For further clarification about specific payer guidelines on “incident to” or split/shared services, please contact your own payer representatives. CMS guidelines on both policies, as well as Anthem guidelines on “incident to” services, are available online by following the links above.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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