Advanced Practice Providers (NPs, PAs, APRNs)

Billing, Supervision, and Delegation of Duties 

An Advanced Practice Provider (APP) is a licensed health care provider (not a physician) that provides medical services typically performed by a physician. The term is commonly used to identify physician assistants and nurse practitioners. APPs typically work under the direct supervision of physicians. Health plans are free to develop their own policies for credentialing and reimbursing APPs. Some health plans may require the APP to be credentialed. Some plans may follow Centers for Medicare and Medicaid (CMS) "incident to" and "direct billing" guidelines. Therefore, it is important to research each health plan to determine their policy regarding AAPPs and incident-to services.

Billing Medicare

Physicians who bill Medicare "incident-to" will be reimbursed at 100% of the Medicare allowable. However, the following criteria must be met:

  • The physician must have seen the patient at a previous visit and developed the plan of care that the APP will carry out.
  • The physician must remain involved in the patient's care and play an active part in the ongoing care of the patient. This does not mean the patient must also see the physician when seeing the APP, but that the physician should see the patient of a frequency that demonstrates the physician's continuing active participation in the patient's care.
  • The APP must be an expense to the physician/practice (employee, independent contractor, etc.).
  • A supervising physician must be physically present in the building. However they do not have to be the physician who developed the plan of care; the claim will be billed with the supervising physician's credentials for that date of service.
  • The services must be provided in the office.
  • Claim requirements: 
    • Enter the name of the physician who performs the initial service, develops the plan of care, and orders the APP service in item 17.
    • Enter the NPI of the supervising physician for the date of service in the lower unshaded portion of item 24J.
    • Enter the signature of the physician providing the direct supervision on the date of service in item 31.
    • When billing incident-to the credentials of the APP will not be reported on the claim, however, some payors require a modifier to indicate the services were incident-to (see our Incident-to Billing Guide).

Important: If the patient is being seen by the APP for a different problem, or has an exacerbation of the current problem, incident-to billing is not allowed. In this instance, the APP must "direct bill" using his/her credentials (NPI, license, etc.). When billing incident-to, the APP should clearly document they are providing care to the patient that follows the physician's plan of care.

Direct Billing to Medicare

When APPs bill directly with their own provider numbers and credentials, Medicare will pay them to perform any service it would pay a physician to perform as long as they are acting within the scope of their state license. These claims are paid at 85% of the physician fee schedule directly to the physician or physician group employing the APP.

To bill Medicare directly, certain rules must be followed. Nurse practitioners (NPs) must have a collaboration agreement with the physician to whom they relate, even if one is not required under state law. Aside from that, the rules for NPs and clinical nurse specialists (CNSs) are the same. Both may assign the right to payment to the employer (this must be done in order for a practice to receive payment for their services), have independent contractor relationships when their services are billed on their own numbers and even establish independent practice groups. Physician assistants must comply with state laws about physician supervision and the protocol by which they collaborate with a physician. They cannot establish independent practice groups, but they can have independent contractor relationships when their services are billed on their own numbers and payment is reassigned to a physician or physician group.

Billing Tools and Resources

Supervision of Duties

Delegation of Prescribing Privileges
The prescribing of drugs and devices is the practice of medicine. Physicians may delegate, if appropriate, but must supervise in accordance with the standard of care. Physicians ultimately may be held accountable for the delegation and supervision of medical acts.

The 2013 legislative changes to Chapter 157 of the Texas Occupations Code/Medical Practice Act removed the site-based requirements for the delegation and supervision of prescriptive authority. It replaced them with a framework that requires the use of prescriptive authority agreements (PAA) in most practice settings, the development of a quality assurance plan, and regular quality assurance meetings. This law reinforces the importance of physician-led medical care teams, recognizes the skills all practitioners bring to patient care, and allows the delegating/supervising physician greater flexibility in tailoring the PAA to his or her practice.

Effective Sept. 1, 2019, 2019 HB 278 streamlines requirements for physicians who have a prescriptive authority agreement with a physician assistant (PA) or advanced practice registered nurse (APRN) by removing the existing requirement for face-to-face meetings between a physician and a PA or APRN and requiring meetings to take place once a month in a manner determined by the physician and the PA or APRN. See Occupations Code Chapter 157.0512.

Also, effective Sept. 1, 2019, 2019 SB 683 contains a provision authorizing physicians to request from the Texas Prescription Monitoring Program (PMP) information on the prescribing activity of an individual to whom the physician has delegated prescribing authority. See Health and Safety Code 481.076.

Texas Medical Association (TMA) has an information sheet that includes a sample Prescriptive Authority Agreement (PAA). Although the law does not state that a specific PAA is to be used, this sample form is very helpful in documenting the minimum requirements.

Once physicians and delegated APRNs and PAs complete the PAA, they each must keep a copy on file for possible future audits by the Texas Medical Board (TMB). Physicians do not need to file a copy of the PAA with the TMB, but they must register any prescribing delegations they make to APRNs/PAs with the TMB, which can be done online.

Refer to the Texas Medical Board (TMB) Supervision and Prescriptive Delegation Registration web page for online registration, eligibility requirements, FAQs, and more.

TMB also has information on Prescriptive Authority FAQs Related to SB 406 and Facility-Based Prescriptive Delegation.

For TMB rules, refer to Chapter 193 Standing Delegation Orders.

Also, see the Medical Practice Act (Occupations Code) Chapter 157: Authority of Physician to Delegate Certain Medical Acts.

More info from TMA - Delegation of Duties and APPs

TMA has developed and gathered resources and legal guidance on delegation of duties, including:

Texas Medical Liability Trust (TMLT) advises TMB rules: Delegation to Mid-level Providers in The Reporter, Volume 1 2014, beginning on page 8.