Professional Role · Topic 4 of 21

Billing, Coding & Reimbursement

Professional role · billing & reimbursement

Billing, Coding & Reimbursement

Medicare pays an NP 85% of the physician rate; in the hospital, split/shared billing — never incident-to — decides whose name goes on the claim.

Key numbers

Medicare pays NPs 85% of physician rate85% of PFS

Critical care: 99291 first 30–74 minutes99291 = 30–74 min

01 · The numberMedicare pays NPs 85% of physician rate

An NP billing Medicare under the NP's own NPI is paid 80% of the lesser of the actual charge or 85% of the physician fee schedule amount — the patient owes the 20% coinsurance.

02 · The ruleCritical care: 99291 first 30–74 minutes

Critical care is billed by total time on the date: 99291 once for 30–74 minutes, then 99292 per additional full 30 minutes (Medicare: first 99292 at 104 minutes); under 30 minutes, no 99291.

03 · The ruleSplit/shared: substantive portion bills the visit

A split/shared visit is a facility E/M done partly by a physician and an NP in one group; whoever does the substantive portion (over half the time, or the substantive MDM) bills, with modifier FS.

The rules

Know these

No incident-to billing in the hospital must knowIncident-to billing (paid at the physician's 100% rate) applies only outside hospitals and SNFs — chiefly the office — for a physician-initiated course of treatment under direct supervision; hospital NPs bill alone or split/shared.

Choose E/M level by MDM or total time must knowSince 2023, inpatient and observation E/M levels are chosen by medical decision making or by total practitioner time on the date; history and exam are done as medically appropriate but do not set the level.

Exclude separately billed procedure timeBundled work (ventilator management, chest x-ray and ABG interpretation, gastric intubation, transcutaneous pacing, peripheral vascular access) is included; time spent on separately reportable procedures is billed separately and not counted as critical care time.

Split/shared critical care: more than half the timeCritical care can be split/shared (since 2022): physician and NP time is summed, and whoever provides more than half of the total qualifying time bills 99291/99292 with modifier FS.

Same group and specialty: one 99291 per datePractitioners of the same specialty and group report 99291 only once per patient per date; a colleague's follow-up critical care is reported with 99292 once an additional full 30 minutes is provided.

Incident-to requires direct supervision in the officeIncident-to services require direct supervision — the physician present in the office suite and immediately available; since 2026 Medicare permanently allows real-time audio-video direct supervision except for 010/090 global surgery services.

Split/shared notes: name both, biller signsSplit/shared documentation must identify both the physician and the NP who performed the visit, and the practitioner who performed the substantive portion — and bills — signs and dates the record.

One inpatient E/M code per calendar dateA practitioner bills only one hospital inpatient or observation code per patient per calendar date, choosing the code that reflects all of that day's services.

What it is

Core idea

Critical care: organ failure with imminent deteriorationCritical care means acute impairment of one or more vital organ systems with a probability of imminent or life-threatening deterioration, requiring high-complexity decision making — not simply a patient's location in the ICU.

Diagnosis & monitoring

Work-up

MDM: meet two of three elementsMDM has four levels (straightforward, low, moderate, high) and three elements — problems addressed, data reviewed and analyzed, and risk of patient management; a level requires meeting or exceeding two of the three.

Top inpatient levels: 75 and 50 minutesBy time, the highest inpatient/observation levels need 75 minutes for an initial visit (99223; 55 for 99222) and 50 minutes for a subsequent visit (99233).

Split/shared or incident-to?

Commonly confused

Setting	Facility (hospital inpatient, ED, hospital outpatient)
Who bills	Whoever performs the substantive portion
Requirement	Physician and NPP in the same group; modifier FS
Payment	100% if physician bills; 85% if NP bills

More detail

Reference

Show 4 reference facts

Medicare prolonged inpatient/observation services use G0316, reportable only when time selects the level and exceeds the 99223 threshold by 15 minutes or more (90 minutes; 65 for 99233).

Non-continuous critical care time on the same date is added together; continuous critical care that crosses midnight is reported as its total continuous time, and any break in service creates a new initial service.

Critical care and an emergency department visit may both be reported on the same day when the patient's condition changes and critical care follows completion of the ED service.

Since January 2024 (unchanged through 2026), the substantive portion of a split/shared visit is more than half of total time or the substantive part of MDM; critical care and prolonged services still use time only.

Pearl

Incident-to lives in the office; split/shared lives in the hospital — and more than half the time (or the key MDM) bills the visit.

Sources · CMS Medicare Claims Processing Manual, Ch. 12 §120 — NP and CNS Services Payment Methodology · CMS Medicare Claims Processing Manual, Ch. 12 §30.6.9 and §30.6.18 — Hospital inpatient/observation E/M; split (or shared) visits · CMS Medicare Claims Processing Manual, Ch. 12 §30.6.12 — Critical Care Visits (99291–99292) · CMS Medicare Benefit Policy Manual, Ch. 15 §60 — Services and supplies incident to a physician's professional service · AMA — CPT Evaluation and Management (E/M) Code and Guideline Changes, 2023 · CMS fact sheet — CY 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F): permanent virtual direct supervision · CMS — Advanced Practice Registered Nurses (APRNs): NP payment at 80% of the lesser of actual charge or 85% of the PFS · CMS — Incident To Services & Supplies (supervising physician bills at 100% of the PFS; direct supervision) · CMS MLN006764 — Evaluation and Management Services Guide (May 2026): critical care 30–74 min = 99291, ≥ 104 min adds 99292, < 30 min do not bill 99291; split/shared substantive portion; incident-to prohibited in facility settings · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).