Seeking Hire Ground Some Guidelines For Utilization of Nonphysician Practitioners — Part I

Non-physician practitioners (NPPs) are being utilized in increasing numbers in physicians offices and facility settings. Some areas are actually experiencing shortages of these health care providers, which include nurse practitioners (NPs), certified nurse midwives (CNMs), physician assistants (PAs), certified nurse anesthetists (CNAs), and clinical nurse specialists (CNs).


The costs of administering health care are increasing at rates exceeding increases in reimbursements. Therefore, physicians need to find ways to increase revenues while still maintaining the quality of health care services rendered to patients. Utilizing NPPs enables physicians to leverage their services and sometimes even expand the ranges of services they can provide.

The success of hiring NPPs depends on the way in which they are utilized in the practice. Many are underutilized and some are utilized in a non-compliant manner. If trained and utilized properly they should, depending on the specialty, generate collected revenue of two to three times their direct compensation. If they are not utilized in accordance with federal and state regulations, i.e., not properly supervised, it could spell disaster for the medical practice.

The purpose of this article is to provide some general guidelines to assist physicians in making the best utilization of NPPs, including determining what to do with them, how to utilize them in a compliant manner and how to bill for their services.

NPPs are healthcare providers. As such, they are also revenue generators for the practice. Utilizing them for non-patient care, such as in administrative support roles, is as much of a waste as using a doctor to schedule patient visits. Such non-clinical utilization should only happen when there are no patients waiting to be seen. In other words, it should be the exception, not the norm.

What Can They Do?

They can render whatever services they are qualified for by knowledge, training and clinical skills acquired, including the evaluation, diagnosis, and treatment of patients with diseases and adverse health conditions. They can manage therapeutic regimens for acute and chronic problems associated with diseases and conditions. They can also issue written or oral prescriptions for controlled substances or other medications.

All of the above must be within the scope of practice as permitted by the state or other jurisdiction under which they are licensed to practice. For example, the scope of practice for NPs, CNMs, and CNAs in Massachusetts can be found on the Web site http://www.mass.gov, by searching for boards of registration. A list will follow to choose from. Select ‘Nurses’ and you will find the site of the Board of Registration in Nursing. Select “Rules and Regulations” and you will find CMR 244-4.00, Massachusetts Regulations Governing the Practice of Nursing in the Expanded Role. If you selected “Physician Assistant” you would find the site of the Board of Registration of Physician Assistants and eventually locate CMR 263-5.04, Scope of Services Which May Be Performed.

Generally, most services rendered by NPPs are E/M services, minor office-based procedures, and ancillary diagnostic procedures. Of course CNMs, PAs and CNAs also may perform in hospital and other surgical settings.

How Do We Bill for Their Services?

First of all, NPPs need to be trained in chart documentation and coding, more particularly with determining the level of service rendered, same as physicians. CMS generally sets the standards for billing, which, unless further restricted by the scope of practice of the licensing state, is generally followed by most insurers.

CMS does not restrict the level of service the NPP can utilize. If supported by the presenting problem(s) and if the complexity or risk of complications associated with the presenting problem supports the medical necessity of a given level of service (1-5), the NPP can bill at that level. Note: On a new or established patient visit, a level one is regarded as an office nurse visit and is rarely, if ever, used by a physician or NPP.

CMS also does not restrict NPPs from performing consultations as long as it is within the state scope of practice and the billing requirements are met, i.e., an opinion must be requested by a physician, an opinion must be rendered and the opinion must be returned to the requesting physician.

Once the E/M service and level of service are determined, there are two ways the service may be billed. One way is the direct billing under the NPP’s name and PIN. The other way is the ‘incident to’ billing under a physician’s name and PIN. If billed direct under the NPP’s name and PIN, CMS (and others) will only pay 85{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the allowable fee. If billed ‘incident to,’ CMS will pay 100{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the allowable fee.

In order to bill ‘incident to’ and get the 100{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} allowable, certain criteria must be met. First, the CMS supervision requirements must be met. These are somewhat complex and will be dealt with in a separate article. Second, the place of service may not qualify for “incident to” service. For example, you cannot bill “incident to” for services rendered in a facility setting such as a skilled nursing facility or in a hospital (inpatient or outpatient). Third, you cannot bill ‘incident to’ for certain services.

For example, ‘incident to’ billing cannot be done for new patient visits (99201-99205) or for an established patient with a new problem. A patient is an established patient if seen within the last three years by a provider in the practice. Also, consultations cannot be billed ‘incident to. They must be direct billed by either the NPP or the physician.

NPPs can perform E/M services in hospitals, such as admissions, visits and discharges, as long as they have hospital privileges and these allow for such services. As mentioned before, all these must be direct billed by the NPP (85{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} reimbursement). Nursing facilities allow NPPs to perform subsequent visits and discharges but only a doctor can bill for the initial comprehensive assessment. All nursing facility services must be direct billed.

Next month, we will discuss the concept of ‘incident to’ services and the supervision requirements.

James B. Calnan, CPA is partner-in-charge of the Health Care Services Division of Longmeadow-based Meyers Brothers Kalicka, PC, Certified Public Accountants and Business Consultants; (413) 567-6101.