What Documentation Is Required for Billing When I Am Supervising a New NP?

Carolyn Buppert, MSN, JD


July 18, 2016

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What documentation is required for billing when I am supervising a new NP?

Response from Carolyn Buppert, MSN, JD
Healthcare attorney

A nurse practitioner (NP) wrote to Medscape with a question concerning her responsibilities during orientation of a new NP.

I am conducting the orientation of a newly licensed and certified NP. She is in the process of obtaining credentials for prescribing and billing. I was told to consult on all of her patients, which I do. What is the best way to document this consultation in the electronic health record?

I will answer this question using Medicare's rules. Commercial payers each make their own rules, and these can vary from payer to payer. Each state makes its own rules on Medicaid, with some input from the federal government. I don't know which payers are in your mix, so I will explain Medicare's rules, which are clear on this issue and which apply in every state.

Medicare allows only qualified clinicians who are Medicare providers—those who have completed the credentialing process and have been assigned a provider transaction access number (PTAN)—to bill and receive reimbursement for physician services. Your NP orientee may be qualified but has not yet been approved by Medicare as a provider. The credentialing process is more than a check to see whether the NP meets Medicare's educational and board qualifications. Medicare also checks to be sure the individual hasn't been barred from Medicare.

Until the orientee completes Medicare's credentialing process, the orientee can't bill Medicare for services rendered. If your employer wants those services billed, then billing will need to occur under your name, or under the name of another Medicare provider. For the bill to be appropriate, you (as the Medicare provider) will need to perform and document the billable aspects of every visit. The billable aspects of the evaluation and management service are the history of present illness, physical examination, and medical decision-making. The orientee may obtain the patient's review of systems, medical/health history, family history, and social history. If the orientee takes the history of the patient's present illness, conducts the exam, and suggests medical decisions, you will need to document that you also performed those services, as well as your findings.

Your scenario may qualify for billing the orientee's services "incident to" your services. Incident-to billing may occur in the office setting (not in nursing facilities, hospitals, or patients' homes). Incident-to billing is allowed only if the patient is an established patient making a follow-up visit. A Medicare provider must already have established the plan of care. Requirements for incident-to billing are found here. And, check with your local Medicare administrative contractor, who may have additional policies on incident-to billing.

Medicaid does not recognize incident-to billing, and requires clinicians to be credentialed and approved to be able to bill Medicaid. So for patients on Medicaid, if a service is to be billed, you or another clinician with a Medicaid provider number will need to perform the billable aspects of the visit. To determine commercial payers' rules governing this scenario, your employer will need to contact each payer.

Note that Medicare requires its providers to understand and follow Medicare's rules. So, although you might think that your employer bears responsibility for following the rules when the employer bills Medicare for your services, you also are responsible for ensuring that services billed under your name are billed appropriately. So, you are wise to ask this question.


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