Billing and coding for mid-level provider seems simple at first but often poses a lot of pitfalls that many private practices, groups, and hospitals are unaware of until they undergo an audit and are levied a hefty fine. Many think the billings rules for nurse practitioners and physician assistants are the same from payer to payer but they are not. Understanding the nuances between the payers is key to obtain maximum reimbursement and remain compliant.

1. BILLING AND CODING FOR MIDLEVEL
PROVIDERS: UPDATES AND STAYING
COMPLIANT FOR 2019
Presented By: Dreama Sloan-Kelly, MD, CCS

2. BUSINESS MATTERS
You will be instructed by the operator when to ask questions – this usually occurs at
the end of the webinar
When a question pops in your mind write it down on a piece of paper so you will
not forget it and have it ready for the lines opening up
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3. ARE YOU READY FOR
SOME FUN?
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4. OVERVIEW
Understanding the ever changing rules in regards to incident billing can save you a
lot of heartache
Must know when it is appropriate to bill for a service incident to
Must know when it is appropriate to bill under the mid-level providers number
All payers are NOT the same
Documentation is Key
Audits
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5. THE TREND
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6. THE TREND
Past few years have shown an increase in hiring of Nurse Practitioners (NP’s) and Physician
Assistants (PA’s) – Mid-levels – to work in the office and assist physicians in managing the care
of patients.
Straightforward if rules are followed but there is a lot of misinformation and confusion
surrounding rules.
Huge compliance risk
Always follow Medicare rules and you will never find yourself in trouble.
It is important to read your private payor contracts and guidelines to make sure they
recognize billing mid-level providers as incident to – or do they want them to be billed under
their own NPI number. If you are a primary care provider you also want to know if the payer
designates mid-levels as primary care providers
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7. LET’S GET SOME OF THE
BASIC DEFINITIONS OUT OF
THE WAY…..
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8. AUXILIARY PERSONNEL
Technical Definition: Any individual who is acting under the supervision of a
physician, regardless of whether the individual is an employee, leased employee, or
independent contractor of the physician, or of the legal entity that employs or
contracts with the physician
Not going to hear this term used much.
Primarily will see it in legal jargon in payer contracts, and any laws that are
created by states in regards to employment in a physicians office or hospital.
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9. PROVIDER
Technical Definition: A health care provider who meets state licensing obligations to
provide specific medical services. Medicare defines a provider to include physicians,
nurse practitioners, clinical nurse specialists, certified nurse midwives, physician
assistants, clinical psychologists, clinical social workers and physical and occupational
therapists.
Most common term used to refer to physicians and non-physician practitioners
Secret: Many doctors do not like the term because it clumps everyone together
Note: Providers are NOT medical assistants or nurses
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10. NPI NUMBER
Technical Definition: A unique 10 character ID assigned by the National Provider
System to providers/suppliers who bill for services or goods. The NPI is the standard
unique health identifier for health care providers. The NPI was mandated by the =
Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Currently ALL providers are required to have an NPI number
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11. NON-PHYSICIAN PRACTITIONER (NPP)
Technical Definition: A health care provider who meets state licensing obligations to provide
specific medical services. For Medicare purposes, the term includes: nurse practitioner or clinical
nurse specialist, certified nurse-midwife, a physician assistant, audiologist, nurse anesthetist,
nurse midwife, clinical social workers, physical and occupational therapist, physician assistant
and registered dietician/nutrition professional. The scope of practice, licensure, and
credentialing requirements for each NPP are established by the law of the jurisdiction in which
the NPP practices. States are responsible for licensing and for setting the scopes of practice.
Please note the above – scope of practice and other rules in regards to NPP’s varies by state
Also that the scope of practice and other rules in regards to NPP’s is a “dynamic” area –
meaning that it changes often so you must recheck on a yearly basis to see what has changed.
AKA: Mid-level Providers
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12. EMPLOYMENT CRITERIA FOR NPP’S
Part-time
Full-time
Leased employee of the supervising physician, physician group practice, or of the
legal entity that employs the physician who provides direct personal supervision.
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13. LEASED EMPLOYEE? IT IS AN EMPLOYEE THAT IS
UNDER AN AGREEMENT WHICH:
The non-physician, although employed by the leasing company, provides services as
the leased employee of the physician or other entity
The physician or other entity exercises control over all actions taken by the leased
employee with regard to the rendering of medical services to the same extent as the
physician or other entity would exercise such control if the leased employee were
directly employed by the physician other entity
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14. THANK YOU
For more information visit https://skillacquire.us
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