Question: How can we maximize reimbursement for services provided
by advanced practice providers?
Answer: “Non-physician provider” (NPP), a term used by Medicare, and “advanced practice provider” (APP) refer to both physician assistants (PAs) and nurse practitioners (NPs). APPs, growing in numbers in the ED space, represent a significant percentage of the labor pool.
Explore This IssueACEP Now: Vol 38 – No 10 – October 2019
The documentation guidelines for the supervision of APPs and reimbursement levels vary by payer and service provided. For Medicare and many Medicaid evaluation and management (E/M) codes, a physician signature alone will result in payment of 85 percent of the physician’s rate. Alternatively, a properly documented split-shared visit should increase the reimbursement to 100 percent of the physician’s rate. Proper documentation requires the physician to indicate face-to-face (direct supervision) interaction.
Check with your local payers for APP supervision requirements. Some payers require the supervising physician to document at least one element of the history of present illness, examination, or medical decision making. For other private payers, a cosignature alone may be sufficient to support APP supervision and payment at the physician’s rate.
Procedures performed by the APP are typically billed under the APP National Provider Identifier and cannot be shared. Critical care may be billed under the APP as long as the APP satisfies the time and medical necessity requirements. Critical care cannot be a split-shared visit. Combining physician and APP time to meet the 30-minute threshold is not valid.
One note of caution: some health care systems may consider the APP a “dependent practitioner” who requires oversight and a cosignature by a supervising MD/DO for all charting. Even in these situations, Medicare may still reimburse at the 85 percent level for these services. However, it is important to understand how each major payer credentials APP’s and what their policy is for supervision, independent services and payment.
For more information, check out our FAQ.
Brought to you by the ACEP Coding and Nomenclature Committee.
Dr. Adler is vice president of practice improvement at Brault in San Dimas, California, and
clinical assistant professor