3 Things to Know About Advanced Practice Providers in Your Practice

Advanced practice providers (APPs), sometimes known as non-physician practitioners (NPPs), are essential members of the healthcare team and serve a lot of roles. But, of course, “essential” doesn’t mean they’re always easy to code for. Make sure you keep these top pointers in mind when you’re completing claims for APPs, such as physician assistants, certified registered nurse anesthetists, and others.

1. Report APP Services Incident to a Physician’s Services for Higher Pay

When you’re talking about Medicare and payers that follow Medicare rules, you can expect APP services reported incident to a physician’s services generally to bring in 100 percent reimbursement. When reporting incident-to services, you bill using the supervising physician’s NPI rather than the APP’s NPI.

So, of course, there are conditions you have to meet. Check out official Medicare resources (like MLN Matters SE0441) for details. Some of the ones you’ll hear most often are that the service must be an integral part of the patient’s treatment and there must be direct supervision, meaning the physician must be present in the office suite to provide assistance if needed.

2. But Watch for When Reporting Under APP’s NPI Is Appropriate

One thing that makes these providers APPs is that they can bill under their own NPIs, unlike ancillary staff such as registered nurses and techs. The services the APP provides need to be within their scope of practice (more on that in the next section), but it’s an important point for making the most of your practice schedule and physicians’ time that APPs may be able to provide certain services independently.

The snag is that Medicare and payers following Medicare rules will reimburse APP services billed under their own NPIs at a reduced rate. You can expect 85 percent payment as the typical amount.

But you can’t choose the NPI to use based on the money. Keep those incident-to reporting requirements in mind to comply with the rules.

3. Check ALL the Rules

Incident-to is known as a Medicare concept, although some private payers allow it, too. Check your specific payers to be sure you’re claims meet their rules.

In addition to insurer rules, APP services and scope of practice may be subject to federal and state regulation, professional organization rules, and facility or organization policy. So be sure your own policy for reporting APP services takes all of those into account to avoid problems for your claims.

What About You?

Do you have trouble tracking APP rules by payer?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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