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Understanding the latest rules for incident-to and split/shared billing can help groups capture full reimbursement and work credit.

Fam Pract Manag. 2023;30(1):13-17

This content conforms to AAFP criteria for CME.

Author disclosures: no relevant financial relationships.

With the current shortage of physicians and the clinical demands on primary care due to the aging and growing population in the United States, a critical need for physician support is arising. The population aged 65 years or older is expected to grow by 45% over the next 15 years, and the general population is expected to increase by 10%.1 One option to assist physicians in delivering care to patients is to add nurse practitioners (NPs) and physician assistants (PAs) to the clinical team.

Both professions originated in training programs around 1965.2 Medicare billing, which initially revolved around physicians, had to morph to include these “non-physician providers” (NPPs) and allow payment for the services they delivered. Since NPP training was shorter in duration, less intense, and more generalized than physician training, reimbursement for their services was also less — set at 85% of the Medicare Physician Fee Schedule (MPFS). This reduced reimbursement rate still stands today for Medicare3 and is commonly followed across other payers, most of which credential NPPs to allow payment for services delivered. Over the years, the NPP name has changed substantially to include qualified health care professionals, advance practice nurses, physician associates, doctors of nursing practice, advanced practice providers, and so on. For simplicity, we will use “NPPs” as an umbrella term for all these providers.


  • In the office setting, services furnished by a non-physician provider (NPP) can be paid at 100% of the Medicare physician fee schedule, rather than 85%, if they are provided “incident to” a physician service and meet certain requirements.

  • In facility settings, split/shared billing occurs when a physician and NPP of the same group each perform portions of a visit on the same patient and on the same date of service; billing is allowed for the clinician who performs the substantive part of the visit based on key components or total time.

  • Physicians risk being “left out” of receiving their part of the reimbursement (and work credit) if the total time option is followed.

The scope of services NPPs can perform is dictated by the originating state governing body — the state Board of Nursing for NPs and the state Board of Medical Examiners for PAs. Though the two types of providers are closely aligned in scope, they are not identical, and rules can vary from state to state. Thus, before deploying this clinical collaboration in your practice setting, it is critical to investigate the scope of services allowed and the governing laws in place in your state. The specific credentialed services allowed need to be annotated in an agreement (Scope of Practice or Practice Agreement) updated on a set schedule to ensure all parties understand what care NPPs can deliver. Most states require the signed and dated document to be readily available at the time of a site visit if one were to occur. Twenty-two states currently allow NPs full (autonomous) practice authority,4 and three states afford the same independence to PAs.5

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