VA CCN April 2025 Provider Pulse

What You Need to Know about Medicare Billing Guidelines for NPPs

The Centers for Medicare & Medicaid Services (CMS) has specific billing rules for services provided by Non-Physician Practitioners (NPP). In accordance with CMS, Medicare NPPs are defined as health care providers working with or under the supervision of a physician. NPPs are also known as mid-level practitioners, physician extenders, or advanced practice providers (APPs). CMS will pay for evaluation and management (E/M) services rendered by the following NPPS: nurse practitioner (NP), clinical nurse specialist (CNS) certified nurse midwife (CNM) and physician assistant (PA).

Reimbursement for NPP Services

NPPs will be reimbursed at 85% of the Medicare Physician Fee Schedule (MPFS) rate unless the service qualifies under the “incident to” provision, in which case the claim is reimbursed at 100% under the physician’s National Provider Identifier (NPI). In certain circumstances, NPPs may bill payers directly rather than billing under a physician.

VA reimburses NPP services when they meet both Medicare coverage and billing criteria:

Requirement/Guidelines Details
Medicare Enrollment NPPs must be enrolled with Medicare and have an assigned NPI.
Scope of Practice NPPs may only bill for services that fall within the scope of their state licensure and certification.
“Incident To” Billing For services provided “incident to” a physician’s care, specific conditions must be met, including physician presence in the office and active management of patient’s care.
E/M, CPT Code Reporting CPT guidance instructs that Evaluation and Management (E/M) (CPT codes 99091, 99202-99499) services should only be reported by physicians. In accordance with CMS guidelines, the only health care professionals that may report E/M services are nurse practitioners (NP), clinical nurse specialists (CNS), certified nurse midwives (CNM) and physician assistants (PA).
NPI Use Use the NPP’s NPI unless billing “incident to” a physician, in which case the supervising physician’s NPI should be used.
Modifiers Use the appropriate modifiers:
  • AS modifier: Use when services are rendered by a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) assisting in surgery.
  • SA modifier: Use when services are rendered by an NPP, particularly when split or shared visits are allowed.

For additional resources see the Medicare Claims Processing Manual or the Medicare Benefit Policy Manual.

Reminder: CCN Providers Must Have Authorization Prior to Rendering Veteran Care

Please remember that any care provided to a Veteran patient under the Department of Veterans Affairs (VA) Community Care Network (CCN) must have prior authorization from VA. If care is provided without this prior authorization, the Veteran cannot be billed for the service.

If authorizations are submitted after providing care to a Veteran and the Request for Service (RFS) is backdated, the authorization will not be approved.

To access and submit an RFS online, VA prefers that providers submit an RFS via HSRM.

  • Visit the VA Storefront
    • Click “Request and Coordinate Care” on the left-hand navigation bar under “For Providers.”
    • Click “Request for Service (RFS) Requirements.”
    • Navigate to the link for the RFS form at the bottom of the section.
  • Send the RFS directly to your authorizing VA Medical Center (VAMC) via one of the following options:
    • VA's HSRM portal (preferable) or an EDI 278 transaction
    • Direct messaging
    • Secure email
    • Secure online file exchange
    • eHealth Exchange

Once approved, providers will receive an authorization letter from either the VA Medical Center (VAMC) or TriWest. Providers can also check the status of an RFS through VA's HSRM, EDI 278 transaction, or by calling the authorizing VAMC.

For more information, see the CCN Processes & Procedures page of the VA CCN Provider Handbook.

Provider Satisfaction Survey Now Available

The Department of Veterans Affairs quarterly Provider Satisfaction Survey is now available. Your feedback is requested to help VA better serve Veterans and you.

Take the survey

Responses are confidential to VA and to TriWest. While the survey is available quarterly, you are only requested to provide your responses annually. We appreciate your participation.

VA CCN Provider Handbook Updates

There are currently no updates to the CCN Provider Handbook.

 

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