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Revised Billing Guidelines for PA/NP Billing

Revised Billing Guidelines for PA/NP Billing

CMS recently introduced guideline changes to its Medicare reporting rules that impact physician assistant (PA) and nurse practitioner (NP) billing. These changes could require practices to modify how they report split/shared services. Previously, shared services were frequently reported in the name of a physician. Now, new rules determine who can report the services. Failing to comply with the new CMS rules will create compliance risks for physician practices. Let’s understand revised billing guidelines for physician assistant (PA) and nurse practitioner (NP) billing.

Revised Billing Guidelines for PA/ NP Billing

Split/Shared Billing

Split/ shared visits are now defined as evaluation and management (E/M) visits in the facility setting that are performed in part by both a physician and nonphysician practitioner (NPP) in the same group. According to CMS, a facility setting means an institutional setting; this could apply to inpatient hospital locations, outpatient hospital locations, observation, the ED, or a skilled nursing facility for selected services.

Chapter 12 of the Medicare Claims Processing Manual no longer includes an office/clinic example. CMS reiterated that if a split/shared visit is performed in an office/clinic setting, incident-to criteria must be met. Office/clinic settings are not all treated the same for billing purposes. Private practices typically report office services using place of service 11 (office), which is not a facility setting. As such, those locations could use incident-to reporting but are not allowed to apply CMS’ split/shared rules. Hospital-owned or academic practices may instead classify their offices as place of service 19 (off-campus outpatient hospital) or place of service 22 (on-campus outpatient hospital). These locations are not allowed to use incident-to reporting but could apply CMS’ split/shared rules.

Substantive Portion

The physician and the PA/NP must each provide a portion of the service with the patient on the same day and document their respective work. The service must be billed by the provider who performs the ‘substantive portion’ of the visit. Previous guidelines also required that both providers provide face-to-face service with the patient on the visit date. The guidance for how much work the physician was required to perform to allow billing was not explicitly described though.

Counting Time

CMS is using CPT’s 2021 E/M guidelines for codes 99202-99215 to define the activities that can be counted toward total time when determining the substantive portion of the visit, whether or not they involve direct patient contact. This is another area where the impact of two sets of CPT E/M criteria is felt: Although the CPT rules for hospital-used codes such as 99221-99233 and 99281-99285 state that unit/floor time can be counted toward visit time, they do not explicitly use this list of qualifying services to determine the level of service. Since 2021, CPT has used this list to determine the level of service for E/M codes 99202-99215, but now CMS has stated it can also be used to determine the substantive portion of other E/M categories.

Face-to-face Contact

CMS now requires that only one of the providers has face-to-face contact with the patient; it is no longer required of both providers. Furthermore, it is not required that the provider who performs the substantive portion has face-to-face contact.


The revised guidelines state that the documentation in the medical record must identify the physician and NPP who performed the visit, and that the individual who performed the substantive portion of the visit must sign and date the medical record. We believe that it is best practice for all providers to authenticate/sign their documentation, even if not required by CMS.

New Modifier

Beginning in 2022, split/shared services must be reported with a new modifier, FS. Note that this requirement does not apply only to split/shared services billed in the name of the physician; if a visit is shared by a physician and PA/NP and the PA/NP performs the substantive portion, CMS still requires the use of modifier FS.

Prolonged Services

During 2022, the CPT codes for prolonged services will depend on the setting. In all settings, the combined time of both practitioners must meet the criteria for the appropriate code, G2212 in the office setting and codes 99354-99359 for other inpatient/outpatient codes, and either method 1 or 2 can be used to determine the substantive portion. In 2023, only the time method will be used to determine the substantive portion.

Practices should apply these revised guidelines only to Medicare patients and should research both state-specific Medicaid guidelines and payer-specific rules to confirm how they compare to Medicare’s revised guidelines. If you need any assistance in Physician Assistant (PA) and Nurse Practitioner (NP) billing contact Medisys Data Solutions at / 302-261-9187

Reference: Medicare Claims Processing Manual Chapter 12

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