BMN Blog

MAR 27
Adding a Mid-Level Provider? Pitfalls to Avoid

In the last 10-15 years, the use of mid-level providers has increased to expand the base of patients in many practices.  The Nurse Practitioner scope of practice is more flexible and there are specialty designations available to foster expertise in certain areas.  The insurance companies have expanded the number of plans covering a mid-level provider’s services. Mid-level provider credentialing is crucial with as many insurance companies as possible to assure billing is possible regardless of the provider the patient is scheduled to see.

We often find physicians are unaware of the billing rules when adding a mid-level provider to the practice. Using time elements suggested in the CPT code description, insurance carriers now have the data to refute a physician’s ability to see a high volume of patients. The utilization dispersion patterns can reflect a physician’s total E&M code dispersion pattern against peers in the same specialty.  A practice employing several nurse practitioners, who provide a number of “incident to” visits, would increase the number of patient visits for a single date of service reflected under the physician’s NPI. “Incident to” guidelines allow the mid-level the ability to see a patient without the physician, but bill service under the physician’s NPI as long as a treatment plan is in place and the supervising physician is present in the office. But, if the patient presents with a new problem and only the mid-level sees the patient, the mid-level must bill for the service.  “Incident to” billing is a Medicare rule and while some insurance carriers are following the Medicare guidelines, Blue Cross of Alabama has stated they do not recognize “incident to”.

Blue Cross of Alabama states the provider who sees the patient should bill the service; laying eyes on the patient is not enough to take over the visit and bill under the physician NPI.  Blue Cross of Alabama allows a shared visit; a mid-level provider could perform much of the visit and document his or her portion of the visit.  The physician should conduct a portion of the history, exam or medical decision-making and document his or her face-to-face involvement separate from that of the mid-level provider.

The supervising physician and the mid-level provider should understand the difference in an “incident to” visit and a shared visit.  Mid-level providers should have their own schedules for patients whom they will bill the service and see independently considering the insurance coverage.  Physicians with a large payer mix of Medicare patients could utilize a mid-level to leverage their schedule by providing “incident to” services for those with a treatment plan.  The practice compliance plan should indicate training on “incident to” and shared visits. A pre-billed review of notes should assure documentation is appropriate for each type of visit. Many practices forego “incident to” billing and shared visits treatment in order to direct bill the services under the NPI of the provider who saw the patient accepting 85% of the full reimbursement for mid-level providers.


Other facets of Incident to and Shared Visits

  • Incident to is only billable in an office or patient’s home
  • A shared visit can be billed in an office, hospital or an emergency room
  • A new patient can be billed as a shared visit but not incident to (no plan from a physician)
  • Any practice who manages a Medicare patient can bill incident to if a plan exist from the physician
  • Shared visits cannot be billed in a skilled nursing facility, critical care, home or domiciliary site nor during consultations or procedure.
  • An urgent care facility is less likely to bill “incident to” due to the lack of follow-up to a plan of care

Utilization patterns related to level 4 and 5 visits are often scrutinized due to the ease of documenting through electronic medical record technology.  In states where a single payer prevails, specialty benchmarks are easily available.  Medical necessity is the overarching criteria for selecting the level of a visit based on the nature of the presenting problem.  A sprained ankle would almost never be a level 4 or 5 visit if the medical decision making was straightforward.

Be prepared to defend the level of the visit, the number of visits on a given date of service, and the supporting documentation of a billed visit should you decide to bill shared visits or “incident to”; big data allows much scrutiny. Once there is an understanding of the guidelines, it is evident that it takes time to provide the services as described. Through counseling, providers can understand the qualitative elements, such as medical necessity, to allow them better judgement in selecting the correct CPT level.  Most providers want to be proficient in documentation and coding, but achieving that proficiency might mean not relying on the code the EMR suggests when signing an office note.

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