Nurse practitioner billing services
Billing for NP-led and physician-NP practices, from the 85% Medicare rate and incident-to rules to split/shared visits and getting each NP credentialed under the right NPI.
Reviewed by Muhammad Ans Zahid, Director of Operations, Business Development, and Credentialing, on 24 October 2026.
Why nurse practitioner billing takes specialty knowledge
Nurse practitioner billing turns on one question that physician billing never has to ask: whose NPI goes on the claim. Bill under the NP and Medicare pays 85% of the physician fee schedule. Bill incident-to under a physician and Medicare pays 100%, but only for an office or clinic visit when the patient is established, the physician's plan of care is in place, and supervision rules are met. Get it wrong and you either leave money on the table or create an overpayment that an audit will find.
SFA Solutions bills for NP-owned practices and for physician groups that employ NPs. Nurse practitioner billing is one of the practice types named on the About page. We match the rendering and billing NPIs to the record. State practice law and the payer contract decide what the NP may furnish. SFA does not make that clinical decision. SFA sets the claim from the enrollment file and the note the practice provides.
Common codes we work with in nurse practitioner
| Code | Description |
|---|---|
| 99203 | New patient office visit, low medical decision making or 30+ minutes |
| 99213 | Established patient office visit, low medical decision making or 20+ minutes |
| 99214 | Established patient office visit, moderate medical decision making or 30+ minutes |
| G2211 | Add-on for the complexity of ongoing longitudinal care, billed with office E/M |
| G0439 | Medicare annual wellness visit, subsequent |
| 99490 | Chronic care management, first 20 minutes of clinical staff time per month |
| 99495 | Transitional care management, moderate complexity, visit within 14 days of discharge |
| 99497 | Advance care planning, first 30 minutes face-to-face |
CPT is a registered trademark of the American Medical Association. Payer rules vary; we check each payer's current policy.
Where nurse practitioner practices lose revenue
The 85% rate and when incident-to applies
Medicare pays services billed under an NP's own NPI at 85% of the physician fee schedule. Incident-to billing pays 100% only when every condition is met: the physician or other allowed practitioner started the course of treatment and remains involved, the visit is in an office or clinic and not a hospital, direct supervision is in place, and the supervising practitioner bills. Since 1 January 2026, direct supervision may be real-time audio and video, not audio-only, for a service that does not have a 010 or 090 global surgery indicator. That option does not make every NP visit a physician claim. A new patient, or a new problem that is not in the plan, is billed under the NP's NPI. Commercial plans do not all follow Medicare. The contract decides commercial payment.
Split/shared visits and modifier FS
Modifier FS is for a split or shared E/M visit in a facility setting where incident-to payment is not allowed, such as a hospital. It tells Medicare that two practitioners in the same group took part and that the claim is billed under the one who performed the substantive portion. For these visits, the substantive portion is more than half of the combined practitioner time, or a substantive part of the medical decision making. Critical care uses time only. Office visits are not billed as split or shared visits, and they do not take modifier FS. A skilled nursing facility E/M visit can be split or shared, except a visit that a physician must perform entirely. A nursing facility visit is not split or shared, because incident-to payment can apply there. The record has to name both practitioners, and the billing practitioner has to sign and date it. We check the setting and the note before the claim goes out.
Credentialing every NP correctly
Each NP needs an individual NPI, Medicare enrollment and reassignment of benefits to your group through PECOS (CMS-855I), a current CAQH profile, and separate enrollment with every Medicaid and commercial plan you accept. Some commercial plans credential NPs as primary care providers and others only allow them under a physician. Under 42 CFR 424.521, Medicare allows retrospective billing for up to 30 days before the effective date only when circumstances precluded enrollment in advance, program requirements including state licensure were met, and the services were furnished at the enrolled practice location. A late application still costs the revenue that rule does not cover.
State practice authority and NP-led practices
Full practice states let NPs evaluate, diagnose and prescribe without physician oversight. Reduced and restricted practice states require a collaborative or supervisory agreement (Texas, for example, requires a prescriptive authority agreement with a delegating physician). Payer rules do not always follow state law: some Medicaid plans and commercial carriers still want a collaborating physician on file before they will pay an NP. We match your enrollment and claim setup to both your state and each payer.
What else affects nurse practitioner revenue
A/R challenges in nurse practitioner practices
A lot of NP A/R starts before the first claim: visits seen while an NP's enrollment is still pending. Under 42 CFR 424.521, a nurse practitioner may bill Medicare for services up to 30 days before the effective date only when circumstances precluded enrollment in advance, the NP had met the program requirements including state licensure, and the services were furnished at the enrolled practice location. A 90-day window applies only when a Presidentially declared Stafford Act disaster precluded enrollment. Most commercial plans will not pay for dates before the NP is credentialed, so those claims age and then write off. The other big source is rendering NPI denials, where a claim goes out under an NP who is not yet linked to the group or under a physician when incident-to rules were not met. We track enrollment dates by payer and hold or route claims so they are not sent under an NPI the payer does not recognize.
Credentialing considerations
Each NP needs an NPI with the right nurse practitioner taxonomy (363L00000X or a population focus such as 363LF0000X for family), a current CAQH profile, and Medicare enrollment reassigned to the billing group. In states that require physician collaboration or supervision, many payers want a copy of the collaborative or prescriptive authority agreement, and some ask for the collaborating physician to be enrolled with them too. Commercial plans also differ on whether an NP can be listed as a primary care provider with an assigned panel, which affects HMO and Medicaid managed care patients.
Payer considerations
Medicare pays NPs at 85% of the physician fee schedule, while Medicaid NP rates are set by each state and commercial plans pay anywhere from a reduced percentage to full physician rates, depending on the contract. Incident-to is a Medicare billing rule, and many commercial and Medicaid managed care plans do not recognize it, so billing under the physician for those plans can be an overpayment. Some plans still decline to credential NPs at all. We check each payer's policy before choosing which NPI goes on the claim.
Nurse Practitioner coding details that affect payment
ICD-10 considerations
Diagnosis codes play a direct role in NP billing because they show whether a visit can be billed incident-to. A follow-up billed under the physician should carry diagnoses from the physician's existing plan of care, and a new diagnosis on that visit is a sign it belongs under the NP's own NPI. NPs managing chronic disease need the same specificity as any primary care practice, such as E11.65 for type 2 diabetes with hyperglycemia or I50.32 for chronic diastolic heart failure, so risk-adjusted plans count the condition. Wellness visits use Z00.00 or Z00.01, and Z79 codes such as Z79.4 for long-term insulin use support monitoring labs the NP orders.
Modifiers to watch
| FS | Placed on split or shared visits in facility settings to show the NP and a physician both took part, with the claim billed under whoever did the substantive portion. |
|---|---|
| SA | Required by some Medicaid programs and commercial plans when an NP renders a service in collaboration with a physician. |
| AS | Used when an NP assists at surgery on a procedure where the payer allows a non-physician assistant. |
| 25 | Added to the NP's E/M when a significant, separately documented problem is managed on the same day as a procedure or wellness visit. |
Global periods
When an NP works in a surgical practice, routine postoperative visits the NP provides during the surgeon's global period are included in the surgeon's payment and are reported with 99024 for tracking only. Minor procedures an NP performs, such as joint injections or skin biopsies, carry their own 0 or 10-day globals.
Medicare considerations
Since 2020, NPs can certify and recertify Medicare home health services and supervise diagnostic tests within their state scope of practice. NPs may also opt out of Medicare and contract privately with patients, which changes how the practice can bill those visits. In a skilled nursing facility, the initial comprehensive visit generally has to be performed by a physician, though NPs can perform other required visits.
Nurse Practitioner billing KPIs to track
- Incident-to eligibility rate. Tracking how many NP visits truly meet incident-to rules prevents both lost revenue and overpayments.
- Revenue held for pending enrollment. Visits seen before an NP is credentialed with a payer often cannot be paid, so this number shows the cost of enrollment delays.
- Rendering NPI denial rate. Claims sent under an NP not yet linked to the group are a common NP-specific denial.
- Average payment per NP visit by payer. NP rates range from 85% to full physician rates by contract, so this shows which contracts to renegotiate.
Nurse Practitioner billing audit checklist
- Confirm every incident-to visit is for an established patient under the physician's existing plan of care.
- Check that a supervising physician was available as required on dates billed incident-to.
- Verify each NP's enrollment and reassignment are active with every payer on their claims.
- Review split or shared facility visits for modifier FS and documentation of the substantive portion.
- Confirm collaborative or prescriptive authority agreements are current where the state or payer requires them.
- Check that commercial and Medicaid claims are not billed incident-to where the plan does not recognize it.
How one office visit chooses the NPI
This is an illustration, not a client result.
On a Tuesday office visit, an established patient is seen for a hypertension plan the physician started last month. The NP's note addresses only that plan and adds no new diagnosis. The physician is in the suite and immediately available, or is immediately available by real-time audio and video. The visit is an office E/M, not a procedure with a 010 or 090 global period. The record shows the plan, the continued involvement, and the supervision. The billing NPI is the physician's. The expected Medicare allowance is 100% of the physician fee schedule.
The same afternoon, the patient is seen for a new skin lesion that is not in the plan. That visit is billed under the NP's NPI at 85%. The new problem is not split off so the rest of the visit can stay at 100%.
If that second visit were in the hospital, it would be billed as a split or shared visit with modifier FS, not as incident-to.
How SFA runs nurse practitioner billing
The practice owns the clinical record, the order, the supervision, and the decision that state law allows the NP to furnish the service. SFA does not supervise the visit and does not decide medical necessity. SFA tracks enrollment, reads the note, selects the NPI and modifiers the record supports, and works denials when enrollment or supervision was the reason.
Related reading: Incident-to billing for nurse practitioners · Credentialing · Pricing · Medical billing services · Contact
We review your NPs' enrollment, supervision arrangements and payer contracts to set the correct billing rules for each provider.
Each visit is checked for incident-to eligibility, split/shared status and modifier FS before the rendering NPI is assigned.
Claims are reviewed against applicable billing, coding and payer-specific rules before submission, and most clean claims go out within 24 hours of final review.
Denials tied to NP enrollment or supervision are corrected and resubmitted, and the root cause is fixed for future claims.
The services that matter most for nurse practitioner
Credentialing & Payer Enrollment
An NP who is not enrolled with a payer cannot be paid by it, and credentialing is included free with every billing plan.
Learn moreMedical Billing
Choosing the rendering NPI the record supports decides whether Medicare pays the NP rate or the physician rate.
Learn moreBilling Compliance
Incident-to and split/shared billing are frequent audit targets, so your documentation has to support the NPI billed on each claim.
Learn moreWhat practices typically see with SFA
Averages and selected client results. Your free audit shows where your own numbers stand today.
Target for the claims we manage, not a measured average.
Highest improvement seen in selected client results.
Largest drop in A/R days seen in selected client results.
Targeted for submission within 24 hours after final review.
From primary care and nurse practitioners to surgery and imaging.
We work inside the system your practice already uses.
Results vary by practice, specialty, payer mix, claim volume, billing history, documentation and other factors. Performance figures represent average or selected client results and are not guarantees of future performance. The 95% figure is a clean-claim target, not a measured cohort. The client-results page does not include a measurement period, starting collections, or practice size.
Nurse Practitioner billing questions
Can a nurse practitioner bill under the physician's NPI?
Only when Medicare's incident-to rules are met for an office or clinic visit: an established patient, a plan of care the physician started, and direct supervision by the practitioner who bills. Incident-to does not apply in the hospital. New patients and new problems must be billed under the NP's own NPI at 85%. Commercial payers set their own rules, and many do not recognize incident-to at all.
Do commercial payers also pay NPs at 85%?
It depends on the contract. Some commercial plans pay NPs the same rate as physicians, while others apply a reduction similar to Medicare's. We review your fee schedules so you know what each payer actually pays for NP services.
Can NPs bill G2211?
An NP who can bill Medicare for E/M services may report G2211 with an office or outpatient E/M visit when the practitioner is the continuing focal point for the patient's needed services, or is giving ongoing care for a single serious or complex condition, and the note shows that relationship. Starting 1 January 2026, the same add-on may also be reported with the listed home or residence E/M codes. Medicare does not pay G2211 when the base visit carries modifier 25, except when the other same-day service is an annual wellness visit, a vaccine administration, or a Medicare Part B preventive service. When the base visit is billed under the NP's NPI, the claim is paid on the NP's Medicare rate, not the physician rate.
How long does it take to credential a new nurse practitioner?
Timelines vary by payer and by how complete the application is. Medicare and Medicaid enrollment and commercial credentialing run on separate tracks, so we start all of them at once. Our article on how long credentialing takes covers typical timelines.
Does Medicare require a collaborating physician for NPs?
Medicare defers to state law. In full practice states an NP can enroll and bill on their own, while in reduced or restricted states the NP must meet the state's collaboration or supervision requirements. Individual payers may add their own requirements on top of that.
See what your nurse practitioner billing is missing
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