top of page

Three Types of Medical Billing Nurse Practitioners Should Be Familiar With

As a nurse practitioner, it’s essential to understand the different types of medical billing that can help optimize your practice. Medical billing is crucial in ensuring you’re reimbursed for services rendered and keeping your revenue cycle flowing. Knowing the specialized tools available with each type of medical billing can help ensure accurate reimbursement while reducing claim denials, chargebacks, and audits.

A photo of a sonogram technician and her patient

Here are three types of medical billing that nurse practitioners should be familiar with:

1. Split/Shared Expenses

A split/shared evaluation/management (E/M) visit is defined as a medically necessary encounter with a patient where both a physician and nurse practitioner each perform a substantial amount of work on the patient on the same date.

Split/shared expenses allow a physician to bill under their codes, rather than the codes of a nurse practitioner at their lower rate. As long as all requirements of a split/shared expense visit are met, there is the possibility for an extra 15% increase in reimbursement. To receive this reimbursement, it is imperative that both parties thoroughly document the visit to prove they both provided a substantial amount of care.

2. “Incident To”

“Incident to” billing is a way of billing outpatient services performed by a nurse practitioner. These services can be performed in an office or institution separate from the main physician’s office, or in a patient’s home.

“Incident to” billing allows a physician to collect 100% of the Medicare Physician Fee Schedule (MPFS), rather than 85% of MPFS care provided by a nurse practitioner. After the initial visit with a physician, if a nurse practitioner does follow up with the patient they are allowed to directly bill under “incident to.”

However, “incident to” billing was developed by Medicare, and not all insurance agencies follow Medicare guidelines. Therefore, it is important to know payer regulations in regard to “incident to” billing prior to a visit with a patient.

3. Direct Pay

Direct pay, and probably the most beneficial to nurse practitioners, is when a nurse practitioner has their own Provider Identification Number (PIN). This number allows a nurse practitioner to bill 85% of the billable physician rate. To obtain a PIN, first, you must have a National Provider Identifier (NPI) and be credentialed with a payer to be able to receive reimbursements. Also, having the nurse practitioner credential allows practices to bill insurance companies directly when the physician is not on-site or has not provided any care to a patient.

Despite the many challenges, there are opportunities for nurse practitioners to get involved in medical billing. It is important to be familiar with the three types of medical billing: split/shared expenses, “incident to”, and direct pay. By understanding these options, Nurse Practitioners can provide quality care while generating revenue for their practices. If you are a nurse practitioner interested in getting started in medical billing, contact us. We would be happy to answer any questions you have and provide resources to help you get started.

71 views0 comments


bottom of page