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INTRODUCTION

The billing and coding guidelines are jointly produced by the American Medical Association (AMA), the Department of Health and Human Services, and Centers for Medicare and Medicaid Services (CMS). NPs are encouraged to check the website periodically for updates and revisions at http://www.cms.gov. The revisions reproduced in this chapter were approved by the AMA and CMS in 2019.

You have been seeing patients throughout your entire NP program. Depending on the practice setting you were in you may have had a lot of exposure to billing and coding or a very limited and confusing exposure. If your NP program utilized a software program such as Typhon1 you had exposure to some of the common Current Procedural Terminology (CPT) used in your specialty area. This information will continue to be helpful to you as you begin practice.

In the practice setting, some NPs continue to have limited exposure to billing and coding and have no idea how much revenue they might generate for their practice. One does not have to become a coder to understand the coding process and billing. Some new employee orientation programs will have a segment that includes some general coding information. There may also be follow-up sessions scheduled as you become familiar with your practice. You should also have access to resources in your practice.

There are currently five major categories of third-party payers. Each payer has its own provider application process, reimbursement policies, and fee schedules. Not all payers allow nonphysician providers to be credentialed or to be credentialed as primary care providers. Some payers have a fixed reimbursement for NPs, for example, 80%, regardless of physician presence in the office or physician consultation. The major third-party payers are Medicare, Medicaid, managed care organizations (MCOs), indemnity insurers, and direct contracts for health services by businesses. Depending on your NP population focus, you may interact with all or some of these payers.

There are many guidelines for billing and it is best to refer to the CMS2 and other individual private payers for specific details. Some examples of billing guidelines refer to the first time a patient is seen to establish care. This visit must be billed under the NPs individual NPI number and those services are reimbursed at the 85% rate. This same guideline applies to established patients who present with a new medical problem—NPs individual NPI number and an 85% reimbursement rate. Other office setting patient visits may be billed under the “incident to” guideline as long as the physician in on site and the reimbursement is at 100%.2 Billing guidelines also vary depending on site where service was performed (i.e., hospitals, skilled facilities, and hospice care).

In most practices the billing is performed by either an individual who may be an employee or a contracted service. Billing and coding are two separate functions. The coder deciphers ...

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