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Coding and Billing for NP and PA Providers in Your Medical Practice


Coding and Billing for NP and PA Providers in Your Practice

How to Bill for Nurse Practitioners and Physician Assistants

You would be hard pressed to find a medical practice in 2017 that does not use Physician Assistants (PAs) and Nurse Practitioners (NPs), also referred to as physician extenders or non-physician practitioners (NPPs).

Understanding how to properly bill and code for services provided by NPPs is imperative to running a cost-effective and efficient medical practice.  Regulations vary by insurance companies and states, so both the physician and the NPP’s must stay current with practice guidelines and ongoing changes.

Nurse Practitioners and Physician Assistants have increasingly become a staple in most medical practices.  NPs are nurses who hold a Master’s Degree or Doctor of Nursing Practice (DNP).  PAs are certified (PA-C), usually holding a Master’s Degree as well.  There are a number of reasons that medical practices utilize these mid-level providers:

  • Reduced Salary expenses (as compared to a physician)
  • Lower overhead costs
  • Higher patient volumes
  • Reduced insurance and liability costs

There are 3 basic types of reimbursement that Medicare provides for these non-physician providers (NPPs). 

Direct Pay

Direct pay is when the NPP holds their own Provider Identification Number (PIN). This reimburses the NPP (or practice) at 85% of the billable physician rate. It is very important that each of your mid-level providers receives his/her own National Provider Identifier (NPI) and be credentialed with each payer to bill under his/her PIN number, if possible, based on payer rules and regulations.  However, many payers will not credential NPPs. Having the NPP credentialed allows practices to bill insurance companies directly when the “supervising physician” is either not on site or has not provided any care or input into patient’s plan of care.

“Incident to”

“Incident to” billing is a way of billing outpatient services rendered in a physician’s office located in a separate office or in an institution, or in a patient’s home provided by a non-physician practitioner (NPP) (See MLN Matters SE0441).  With incident to billing, the physician bills and collects 100% of Medicare’s allowable reimbursement.  This type of billing is used when an NPP sees a patient in which the physician has performed the initial service and has initiated a Plan of Care or treatment plan.  There are specific rules for this type of billing, the physician must be on site, in the suite, not just in the building, and provides direct supervision (the rules for home visits varies).

By filing a claim “Incident to”, the physician can collect 100% of the Medicare Physician Fee Schedule (MPFS) instead of 85% of the MPFS for care provided by a qualified NPP.  New patients should be seen by the physician to set up the Plan of Care and this would be billed under the rendering physician.  After the initial visit, the NPP can provide follow-up care based on the Plan of Care, billing for direct care as “Incident to”.  If adjustments are made to the plan of care such as medication changes, then the physician should see the patient face to face in order to adjust the original plan of care, otherwise, the visit may not qualify for “Incident to” billing.

“Incident to” billing was developed by Medicare and not all commercial insurance carriers follow Medicare guidelines, therefore knowing payer regulations regarding “Incident-to” billing is imperative prior to providing patient care.

Split/Shared Expenses

Split/shared expenses:  “A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer.”

Billing for shared/split services allows the practice to bill under the qualified physician versus the NPP at their lower reimbursement rate.   As long as the criteria are met, billing for shared/split services allows for that extra 15% reimbursement.

Documentation is paramount in this type of billing.  Each practitioner must thoroughly document the care they provided to substantiate reimbursement under the split/share guidelines allowing both parties to bill for care.

According to the Centers for Medicare and Medicaid Services (CMS), shared/split visits are applicable for services rendered in the following settings:

  • Hospital inpatient or outpatient
  • Emergency department
  • Hospital observation
  • Hospital discharge
  • Office or clinic (when “incident-to” requirement are met)

Shared/split visits are not allowed:

  • In a skilled nursing facility or nursing facility setting
  • For consultation services
  • For critical care services
  • For procedures
  • In a patient’s home or domiciliary site


With shifts in healthcare spending, patient care, and reimbursement, and physician shortages, the need for Nurse Practitioners and Physician Assistants is greater than ever.  A Proper understanding of the billing and reimbursement guidelines for individual payers is necessary.  Charting and documentation requirements must be met.

Does your medical practice use NPs or Pas? Are you billing “Incident to”? Let me know in the comments below. 



— This post Coding and Billing for NP and PA Providers in Your Medical Practice was written by Manny Oliverez and first appeared on Capture Billing. Capture Billing is a medical billing company helping medical practices get their insurance claims paid faster, easier and with less stress allowing doctors to focus on their patients.

Capture Billing

Tips for billing for observation

Tips for billing for observation

Editor’s note: The following is an excerpt from the Observation Services Training Handbook. For more information, visit


Observation hours start accruing not when the patient comes into the hospital, but when the physician writes the order for observation. Observation hours end when all medically neces¬sary services related to observation are complete.

In some cases, this means that you can still bill for time spent completing the patient’s care after the physician writes the discharge order.

For example, a physician comes in to see the patient at 7:30 a.m. and writes the discharge order, which states discharge will occur pending the completion of tasks X, Y, and Z. The nursing staff finishes up those three tasks and the patient is finally ready to leave the hospital at 11 a.m. The hours between 7:30 a.m. and 11 a.m. are potentially billable observation hours because they were used to complete the patient’s medical care.

Observation hours therefore end not with the discharge order but with the completion of medical services.

In addition, because observation services are considered a tempo¬rary period to aid in decision-making, CMS states in the Medicare Benefit Policy Manual that only in rare and exceptional cases should observation services last more than 48 hours.

If a case reaches the 48-hour mark and the physician still hasn’t made a decision to discharge or admit the patient for inpatient care due to instability or risk of an adverse event if discharged, nor has any documentation made a compelling case for the need to continue observation, the services no longer meet the defini¬tion of observation care and the hospital should not bill for future hours. Hospitals should also not report observation hours after the physician has decided to send the patient home or to a lower level of care if the patient is receiving no active treatment and is just in a holding pattern until he or she moves to the next level of care or goes home.

Coding for comprehensive observation services

The 2016 outpatient prospective payment system final rule implemented changes for coding and billing for observation services. Among the changes made by CMS was the creation of a new Comprehensive Ambulatory Payment Classification for comprehensive observation services (CMS, CMS Finalizes Hospital Outpatient and Ambulatory Surgical Center Policy and Payment Changes, 2015).

Specifically, hospitals will now bill all qualifying extended assessment and management encounters, including observation services, through the newly created comprehensive observation services C-APC code 8011. A new status indicator, J2, was also created to specify that more than one service was provided (80 Federal Register 130, 2015).

CMS now requires hospitals to bundle services provided and previously billed separately?services such as level 3 ED visits, IV infusions, echocardiograms, speech therapy, and similar services. CMS pays a flat rate for the comprehensive observation services, which includes the bundled services.

Hospital staff should bill all hours of observation for a single encounter on one line under revenue code 0762. If the hospital provided observation care to a patient over multiple days, the date of service should be the date that observation care began. Although one rate is now paid for comprehensive observation ser¬vices, HCPCS code G0378 is still used to bill observation services by the hour. When using this code, the organization should round to the nearest hour. For example, eight hours and 20 minutes in observation would round to eight hours, whereas nine hours and 40 minutes would round up to 10 hours. If the hospital provided observation care to a patient over multiple days, the date of ser¬vice should be the date that observation care began.

The second HCPCS level II code for observation is G0379. This code is used for a direct admission or referral for observation care from a physician in the community. Note that this code is not used if an ER physician or a physician from a provider-based department or clinic makes the referral. This code previously allowed hospitals to bill for costs associated with the visit, including registration and collecting clinical information about the patient, but costs are now bundled with the payment for the comprehensive observation services. – HIM Briefings

Common SNF billing struggles

Common SNF billing struggles

Written by Lisa McIntire and Julie Bilyeu of BKD, LLP.

With ever changing billing requirements and increased payer scrutiny, skilled nursing facility (SNF) billing personnel encounter more challenges than ever. Providers that don’t stay on top of changes that impact billing are at risk for noncompliance and decreased cash flow. Oftentimes billing issues can be avoided with ongoing education, consistent review of outstanding accounts receivable, and a thorough process for pre-submission claims review.

Lack of understanding about payment methodology

It sounds simple enough, but understanding how each payer reimburses for services is critical to determining if claims are paid correctly.

Important components of Medicare payment methodology include knowing when rates change annually. This can be confusing since Part A rates are updated in October, while coinsurance and Part B rates change each January. If the new rates aren’t loaded into billing software in a timely manner, accounts receivable will not be accurate, which can make follow-up daunting.

Other considerations include accounting for the 2% sequestration cut that has been in effect since April 1, 2013, and the Multiple Procedure Payment Reduction (MPPR) that applies to certain therapy service codes, both of which your software may or may not apply automatically.

Knowing what to expect in reimbursement from insurance primary and Medicare Advantage (MA) plans can also be confusing. Providers often mistakenly assume these plans pay according to Medicare guidelines; however, contracted providers are generally paid a daily rate based on level of care or charges billed. Insurance payment rates may not change, depending on how often the contract is renegotiated, so it is advisable to review your contract on an annual basis.

Determining patient out-of-pocket costs is another burden, as it can vary greatly by payer. But the earlier patients are notified of their financial responsibility, the higher the likelihood the SNF will be able to collect.

Overlooked adjustments and bad debt write-offs

A common theme surrounding aged accounts receivable (AR) is that the claims have paid, but a balance or credit balance remains after the payment was applied. Just because the claim paid does not mean the situation is finalized. If a balance remains after payment posting, further investigation is in order?and the sooner, the better.

Otherwise, these incorrect balances build up over time, making it difficult and time-consuming to determine later if claims were correctly paid or if there are balances that need to be collected or reported as overpayments. This also contributes to inaccurate AR, which can lead to increased scrutiny by stakeholders as well as unrealistic expectations about cash yet to be collected. However, these issues can be easily avoided by researching any discrepancies at the time payments are posted as well as determining?and resolving?the core issue.

As previously mentioned, incorrect rates in billing software is a common contributor to inaccurate AR balances. Depending on the state, Medicaid rates may change as often as quarterly, which requires even more diligence in ensuring they are correct. Not adjusting for sequestration and MPPR, as detailed on the Medicare remittance advices (RAs), is another reason why balances remain after claims have paid.

For providers with a high volume of MA claims, contractual adjustments can come in many forms, depending on how the receivable is recorded in the billing software. The best way to mitigate the number of necessary adjustments is to take time to proactively set up each insurance payer in the software with detailed reimbursement criteria, which may be based on a daily rate, RUG rates, or total charges billed. If you invest the time on the front end, there will be fewer adjustments to make post-payment.

Reclassifications between payers also need to be done as quickly as feasible. For example, when Medicare processes full pay and coinsurance days differently than what was entered into the billing software, this often results in the need to reclassify a balance from one payer to another which, if not done, will result in an erroneous balance “due” from one payer and a credit balance under the other payer. Not reclassifying patient responsibility amounts also seems to be a pitfall particularly applicable to MA or insurance primary plans.

Reviewing AR to determine which accounts are uncollectible should be done on a quarterly basis, but no less than annually. It is imperative that write-off criteria and approval processes are clear and easily understood by billing personnel as well as monitored closely by management. This is especially important as it relates to Part A coinsurance bad debts that are potentially reimbursable on the year-end cost report.

Lack of adequate training and resources

Throughout the last several years, Medicare?and in many states, Medicaid?billing has become increasingly complex. Gone are the days of straightforward scheduled assessments and simple Part B claims.

With the addition of many types of unscheduled assessments?Start of Therapy (SOT), End of Therapy (EOT), and Change of Therapy (COT), just to name a few?Part B 59 and KX modifiers, and more recently, G codes, which are used to report functional limitations, the importance of providing thorough training and reliable resources for billing staff cannot be overstated.

As anyone who has billed for SNFs knows, it is very unlike billing for any other provider type. All billing is not equal, and expecting someone who has billed for a physician’s office or hospital, for instance, to acclimate to SNF billing with little or no training, is unrealistic and will likely have a negative impact on compliance and overall revenue cycle health.

But just as billing for SNFs is unique, not all training options are equal. It can be tempting to choose low cost or free options, such as articles or webinars offered by the Medicare Administrative Contractors (MACs), but keep in mind that these general resources, while helpful, do not typically provide the detailed knowledge your business office manager will need to not only create and submit claims but also to follow up on the claims appropriately and resolve any technical errors or payer disputes efficiently. Be willing to seek out?and invest in?quality training and consulting resources to ensure your billing team has ongoing access to the latest technical information and guidance around best practices.

To be expected, as billing has increased in complexity, so has billing software. Many integrated systems are highly customizable, which can be exciting or overwhelming, depending on the skill and knowledge of billing personnel. Also depending on the size of your organization, it may be necessary to review and change processes to improve overall efficiency and effectiveness.

Poor clinical to billing communication

Since the inception of minimum data set (MDS) 3.0, it is more important than ever that billers and clinicians communicate frequently and collaborate in a pre-claims submission review process each month. This review process is commonly referred to as triple check, since it includes representatives from nursing, therapy, and billing.

The purpose of the triple check process is to confirm information on the UB-04 claim forms against the supporting documentation. Many times providers only review the information generated by their clinical and/or billing software; however, that information can be overridden on the claims due to software glitches or other factors.

A thorough triple check review should include verifying patient demographic information, ancillary charges, and billing and diagnosis codes, among other items on the claim form. Triple check should also include verification of required items from a compliance standpoint, such as signed physician orders, certification for skilled care, and validation reports to confirm assessments were accepted. ?Conducting the triple check meeting should be the final step before any claims are billed?to improve compliance as well as providing billing and nursing with peace of mind that what is being billed is accurate and supported by the documentation on file.

Another benefit of triple check is helping billing identify any assessment issues, such as late, early, or missed assessments, all of which have billing implications. For example, if an assessment has an assessment reference date (ARD) that is outside of the allowed window, the claim must be billed with a default resource utilization group (RUG) code of AAA for the number or days the assessment was out of compliance. If an assessment was missed altogether, those days would be billed as provider liability, which results in no reimbursement to the provider. The guidelines for early, late, and missed assessments can be found in chapters 2 and 6 of the resident assessment instrument (RAI) manual.

Going forward, billing and revenue cycle management are not going to get easier. But by implementing some relatively simple but highly effective best practices, and ensuring that the personnel most directly responsible for cash flow have thorough training and helpful resources, SNFs can thrive despite increased regulatory complexity and oversight. – Billing Alert for Long-Term Care

billing multiple injections and services the same visit: different dx? Correctly

I work for a family practice that sees clients for multiple reasons within the same visit. Can you tell me if the scenario listed below is the correct way to bill for the visits with the modifiers? I am afraid that I am using to many modifiers and that I only need to utilize modifier 59 once. Any help is GREATLY appreciated!!!:confused::confused::confused:

E & M 99214 with Modifier 25 DX E11.9, M54.5
96372 with Modifier 59 R53.82
J3420 Vitamin B12 injection DX R53.82
96372 Modifier DX 59 M65.341
Ji885 Toradol injection

Medical Billing and Coding Forum

Best Practices in Radiology Patient Billing

 Maximizing the patient experience is no longer limited to the achievement of clinical success. It is a critical component of the new, broader partnership between provider and patient – one that now encompasses conversations regarding not only service quality and cost, but also places a greater focus on practice billing processes in line with the higher demands inherent to the new patient consumerism trend.  


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Radiation Oncology coding and billing

Hello! I am new to radiation oncology coding and billing. Does anyone have any resources, cheat sheets or tips they would be willing to share with me? Anything would be greatly appreciated! I am tasked with coding radiation therapy, charge entry and working back end denials that have been sitting for awhile.

Also, my employer is looking to send me to a workshop or seminar. Does anyone know of any on the east coast after October 1st?

Medical Billing and Coding Forum

Buckeye Mycare Ohio-Podiatry Billing

We are having trouble getting podiatry claims paid by Buckeye Mycare Ohio. The denials are for bundling.
For example, the doctor billed:
99307- 25
11730-toe mod
11732- toe mod
11721- Qmod and 59

All LOS pay except for the debridement, and it comes back bundled. Does anyone have any suggestions?

Thanks in advance

Medical Billing and Coding Forum