Improper Billing of Mid-Level Practitioner Services

Last week, the Department of Justice (DOJ) announced a $516,718 false claims settlement related to improper billing of mid-level practitioner services using a physician’s provider number.

Medicare reimburses nurse practitioner and physician assistant services at a reduced rate of 85% of the Medicare allowable when billed under the mid-level practitioner’s  provider number.  In select situations, the mid-level practitioner’s services may be billed using a physician’s provider number and receive payment at 100% of the Medicare allowable.

Medicare limits billing of mid-level practitioner services using a physician’s provider number to instances where either the Medicare incident to or split/shared billing requirements have been met.   An overview of the requirements are as follows:

Incident toSplit/Shared
Place of service (POS) 11 onlyFacility place of service only, excludes POS 11
Established patients onlyNew or established patients
Established problems onlyNew or established problems
Provided in accordance with established treatment plan developed by MDNew or established treatment plans
Rendered by APP only under direct supervisionRendered by APP and physician
Billed physician’s provider numberBilling provider determined based on the performance of the substantive portion of the encounter
No incident to modifierModifier FS required on all claims for split/shared services

Compliance with the incident to rules has been a known risk area for years with multiple published settlements and audit reports.  Providers have also struggled with operationalizing and achieving compliance with the current split/shared billing requirements.  In fact, many providers have indicated their electronic health record systems do not allow them to appropriately document and bill split/shared encounters in accordance with the current requirements.

We recommend conducting routine auditing and monitoring of incident to and split/shared services to confirm compliance with the documentation and billing requirements. 

The DOJ press release is located here:

The Medicare Claims Processing Manual requirements are located here:

We are here to help.  The HBE team is available to assist you with all of your coding, billing and compliance program needs.  We routinely provide compliance partner services to large health systems as well as physician practices. Our services include:

  • Coding accuracy reviews
  • Risk Assessments
  • Clinical documentation improvement reviews
  • Policy and procedure development
  • Customized education and training for clinical and administrative staff

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