Physician Extenders

Billing and the supervision-delegation of duties and prescribing privileges to PAs and APNs.

A physician extender, or non-physician practitioner, is a licensed health care provider (not a physician) that provides medical services typically performed by a physician. The term physician extender is commonly used to identify physician assistants and nurse practitioners. Physician extenders typically work under the direct supervision of physicians.

Supervision of Duties

Billing Health Plans

Health plans are free to develop their own policies for credentialing and reimbursing physician extenders. Some health plans may require the physician extender to be credentialed. Some plans may follow Centers for Medicare and Medicaid (CMS) "incident to" and "direct billing" guidelines. Therefore, it is important to contact each health plan to determine their policy regarding physician extenders.

Billing Medicare "Incident To"

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

  • The physician has to have seen the patient at a previous visit and developed the plan of care that the physician extender will carry out.
  • The physician has to remain involved in the patient's care.
  • The physician extender has to be an expense to the physician/practice.
  • 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.

Important: If the patient is being seen by the physician extender for a different problem than the physician developed the plan of care for, then this does not qualify as "incident to". In this instance, the physician extender must "direct bill" using his/her credentials (NPI, license, etc.). Also, the physician extender should clearly document they are providing care to the patient that follows the physician's plan of care.

Direct Billing to Medicare

When physician extenders bill directly with their own provider numbers, 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 physician extender.

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

  • Novitas Incident-to Tool - Novitas Solutions has developed an interactive self-service tool to assist you in determining when a non-physician practitioner's service can be billed under "incident-to" provisions.
  • HCMS Reference Guide - HCMS has developed a reference guide for reimbursement for nurse practitioners and physicians assistants for in-office services. This guide is designed to provide physicians and their staff with information regarding billing for physicians extenders.
  • MLN Article -Incident-to Services
  • TMA Guide (Collaboration/Supervision section)
  • AAFP Article

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 Non-physician Practitioners

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.