Billing Basics for Nurse Practitioners & Physician Assistants

By Kathryne Plato, CPC | Director of Coding at ebix

In a previous newsletter, we looked at billing rules for locum tenens physicians. Now let’s look at the billing basics for Nurse Practitioners (NP), Clinical Nurse Specialists (CNS) and Physician’s Assistants (PA).

NPs, CNSs and PAs may apply for individual provider numbers for direct billing purposes.  All covered services rendered may be billed using the advanced practitioner’s direct provider number. The categories of third-party payers who may reimburse for NP/PA services are:

  • Medicare
  • Medicaid
  • Commercial indemnity insurers
  • Commercial managed care organizations

Each of these categories of payers and each of the commercial insurers has different rules on reimbursing NP/PA services.

Medicare’s Basics
To bill Medicare for services, an NP or PA must show that:

  • He or she meets Medicare qualification requirements.
  • The Practice accepts Medicare’s payment, which is 85% of the physician fee schedule rate for bills submitted under the NP/PA’s provider number.
  • The services are for “physician services” or those for which a physician can bill Medicare.
  • The services are performed in collaboration with a physician.
  • The services are within the NP/PA’s scope of practice as defined in state law.
  • No facility or other provider charges or is paid with respect to the furnishing of the services.

Medicare & Non-Physician Practitioner (NPP) & Shared/Split Services
A “Shared/Split Service” is for services provided when both the physician and a non-physician practitioner (NPP) provide, document and sign the work they each performed.  If the guidelines are met, the physician can bill the encounter to Medicare, not having reimbursement reduced 15%.

To bill for a shared service, there must be a documented face-to-face encounter with the physician. A note stating “seen and agree” or “agree with above” by the physician would not support a shared/split visit.

Critical Care services may not be billed as a shared service.  Non-physician practitioners may bill Medicare for Critical Care services.  However, it must be within the state scope-of-practice or the hospital policy does not require physician-supervised care in the life-or-death situations those codes cover.

Two or more doctors within the same group can provide critical care to the same patient in the same day and bill for their combined time, but this is not true with NPPs.  If the NPP provides the first hour and the physician provides the second half hour, it will have to be with two separate codes.

ABOUT ebix
ebix inc., Greendale, WI, is a revenue cycle management firm offering independent Emergency Room physician groups coding expertise, denials minimization and data analytical services. For an average client, ebix inc. generates an additional 10% of revenue. ebix provides complete, consistent and timely medical coding and billing services, letting physicians focus on the excellence of their patient care, not back room operations. To learn more, please visit