This book is written for physicians, nurse practitioners, and physician assistants together, because the coding rules are largely shared. But a few rules apply specifically to advanced practice providers, and they have real financial consequences for the clinician and the practice. This chapter covers them directly.

First, the Vocabulary

Advanced practice provider, or APP, is the umbrella term used throughout this book for clinicians who evaluate and manage patients without being physicians: nurse practitioners (NPs), physician assistants (PAs, increasingly titled physician associates), clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists. Medicare often calls this group non-physician practitioners. The terminology varies; the coding implications are what matter.

The 85 Percent Rule

Here is the single most important fact about APP billing, and it surprises many clinicians the first time they see it. When a service is coded and submitted under an APP's own national provider identifier, Medicare pays 85 percent of the physician fee schedule amount for that same service. The work is identical, the code is identical, and the payment is fifteen percent lower. A 99214 generates the same wRVU value regardless of who performed it, but the dollars Medicare returns differ based on whose number the claim goes out under.

This is why the incident-to and split/shared rules from the previous chapter carry such financial weight. When an APP's work is legitimately billed incident-to a supervising physician, or as a split/shared visit under the physician, the practice receives 100 percent rather than 85. That fifteen percent gap is the entire economic reason those billing pathways exist, and also the reason they draw audit scrutiny: the temptation to bill at the physician rate when the strict requirements were not actually met is exactly what auditors look for.

A second detail worth knowing: physician assistants historically could not bill Medicare directly at all, with their services submitted under a supervising physician or the practice. The rules have evolved and vary, but the practical point stands that the billing arrangement, not just the clinical work, determines the payment.

What This Means for an APP Reading This Book

Everything in the rest of this book applies to you. The MDM table, time-based billing, the modifiers, the specialty chapters, all of it governs your coding exactly as it governs a physician's. The 85 percent adjustment is applied downstream by the payer; it does not change how you select a code or what your documentation must say. Your job is the same: code accurately for the work you did, and document it so the level holds up. Whether a given visit is then billed under your NPI at 85 percent or under a physician at 100 percent is a practice-level decision governed by the incident-to and split/shared rules, and it is worth understanding how your group handles it, because it directly affects the value attributed to your work.

A Note for Practices

For a practice deciding how to deploy APPs, the coding rules create a real tension worth naming honestly. Incident-to and split/shared billing recover the fifteen percent, but only when the clinical and supervision requirements are genuinely met, and the compliance risk of getting it wrong is significant. The durable answer is not to bill aggressively at the physician rate and hope, but to build workflows where the requirements are actually satisfied and documented, or to accept the 85 percent where they are not. Accurate coding, again, is the standard in both directions.

Sources and Further Reading for This Chapter

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