Advance Practice Non-Physician Providers (APNP)
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This page serves as an anchor for related billing and coding articles for APNP coding/billing.
Advance Practice Non-Physician Providers (APNPs) have been called many different things over the years. The titles change as often as governmental regulations. Some of the names you may remember are, most recently (APP) Advance Practice Provider or (NPP) Non-Physician Practitioner. But whatever the decided upon title is, just know that there are different billing rules for them than your residents. Who also have different titles. More about that later.
Who are APNPs?
Not an all-inclusive list:
- PA (Physician Assistant or Associate)
- NP (Nurse Practitioner)
- CNS (Certified Nurse Specialist)
- CRNA (Certified Registered Nurse Anesthetist)
- CNM (Certified Nurse Midwife)
CMS – APNPs and Incident-to billing:
“Incident to services and supplies are those provided as an integral, although incidental, part of the physician’s or nonphysician practitioner’s personal professional services during diagnosis and treatment. Physicians, Nurse Practitioners (NPs), Certified Nurse-Midwives (CNMs), Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) are nonphysician practitioners who are authorized to have services provided by auxiliary personnel.”
CPT and CMS often refer to services that may be performed/reported by either a physician or APNP in statements such as “may be performed by physicians or other qualified healthcare professionals”. APNPs are recognized to perform and report E/M (Evaluation and Management) services directly for 85% (Medicare) or 92% (Medicaid). The “exception” to this is the Incident-to or Split/Shared provisions. These exceptions allow the APNPs E/M service to be reimbursed at the higher 100% of the MPFS (Medicare Physician Fee Schedule).
Like everything else, if you want more, you have to do more. The Incident-to and Split/Shared requirements are quite extensive. If you do not meet all the requirements, the service must be reported directly under the APNPs name.
How are other non-physician professionals classified?
- Audiologist – CMS has approved 36 CPT codes in 2023 that they may bill without a physician/APNP order (using -AB modifier).
- PT/OT/SLP – They each have their own therapy/modality codes in the CPT Medicine Section
- Licensed Clinical Social Worker – may report a variety of codes independently
- RD (Registered Dietician) – may perform MNT and DSMT (must be in an accredited diabetes program) services
Keep in mind, many of these services performed by licensed professionals may have their own benefit category and as such, may not be reported as an incident-to service. Audiology, DSMT (Diabetes Self-Management Training) and MNT (Medical Nutrition Training) services are perfect examples.
So, what’s the Problem?
Many physicians are confused about how to report services for APNPs as they clinically function much the same way as their Intern, Resident, or Fellows (collectively known as – Resident, by CMS). Although the workflows may be very similar, the billing rules are not. Teaching physician rules do not apply to APNPs. Though I should not have to say it, APNPs may not supervise residents, or share services with them for “billing purposes”.
Interestingly, each type of APNP has slightly different billing requirements. Therefore, it is important to learn how to most efficiently and compliantly utilize the APNPs in your practice.
(POS) Place of Service – Matters!
If you are utilizing your APNP in the Clinic/Office setting, your options are direct billing or Incident-to. The cleanest of the two, is direct billing by the APNP. That said, it comes at a cost. APP services are typically reimbursed at 85% of the MPFS or 92% of Medicaid. If you want to capture that additional revenue, there are some hoops to jump through first.
If your APNPs perform E/M services in the facility setting, your option besides direct billing, is Split/Shared. There is no Incident-to in the facility setting, just as there is no Split/Shared in the clinic setting. Also, shared/split visits only apply to certain types of evaluation and management services.
Supervision Requirements
For services being reported as incidental to the physician (i.e., Incident-to), there must be direct physician supervision. Direct supervision puts the physician in the suite (FEET in the SUITE!), but not necessarily in the room, with the APNP and the patient. The supervising physician must be “immediately available” but does not have to be the physician who wrote the original plan of care. That said, the physician who supervises, bills. It is the responsibility of the APNP to document who was in the clinic supervising at the time of the encounter. It is not a recommendation. It is a (Novitas) requirement to bill Incident-to services to Medicare patients.
We have written several articles outlining both Incident-to and Split/Shared billing to get you started. If you would like to discuss these topics at one of your faculty meetings, please reach out to your UT Health compliance liaison found on the Meet the Team page.
You may also contact [email protected] or [email protected] to schedule a meeting.
MSHBC Resource Articles
Shared/Split Visits: 2024 Rules
Shared Visits – Still Puzzled?