MID-LEVEL BILLING

by Cheryl Nash

Confusing on the best of days, commercial payers are creating new guidelines surrounding the billing practices for Mid-Level providers. Initially categorized under Non-Physician Practitioner (NPP) and more recently referenced under Advanced Practice Provider (AP) these policies vary greatly in what the payer will allow in regards to who/what NPI is required as the rendering provider on the claim.

Mid-Level billing falls under 2 categories:  Direct billing and Incident-To billing.  Direct billing is when a claim is submitted under the Mid-Level’s NPI and the payment is typically reduced to 85% of the contracted fee schedule.   Incident-to billing is when a claim is submitted under the supervising Physician’s NPI and paid at 100% of the physician’s fee schedule.

Here is where the rules get tricky. Incident-to billing was created by CMS (Medicare) and technically applies only to Medicare claims.  In the past Commercial payers tended to follow these guidelines to some degree, but in recent years they have diverged from the CMS rules and created their own policies.  These policies may be completely different for each payer.  Some effectively exclude incident-to billing of any kind. An example is Cigna’s policy # R37.

Others follow CMS to some degree, but may require a modifier to indicate the service was performed by a Mid-Level. Other payers may not credential Mid-Levels and all claims must be billed under the supervising physician. It is imperative to read these guidelines and understand how your payers want these claims submitted or risk being in violation of your contract.  Billing incorrectly to any payer can be considered a false claim with significant consequences when the practice is being paid at a higher fee schedule than they would if billed appropriately under the contracted payer’s guideline.

One key element you should be aware of is location proximity. You should only bill Incident-To if the physician and the Mid-Level are co-located in the same office. Otherwise, the claim should be sent under the Mid-Level (payer policies not with-standing).

We do recommend that you add your Mid-Level provider to your existing contracts if they allow it. This will eliminate the need to ‘fudge’ the Incident-to billing guidelines should the care rendered not fall into this category.