Scope of Physician Procedures Independently Billed by Mid-Level Providers in the Office Setting

Importance  Mid-level providers (nurse practitioners and physician assistants) were originally envisioned to provide primary care services in underserved areas. This study details the current scope of independent procedural billing to Medicare of difficult, invasive, and surgical procedures by medical mid-level providers.

Objective  To understand the scope of independent billing to Medicare for procedures performed by mid-level providers in an outpatient office setting for a calendar year.

Design  Analyses of the 2012 Medicare Physician/Supplier Procedure Summary Master File, which reflects fee-for-service claims that were paid by Medicare, for Current Procedural Terminology procedures independently billed by mid-level providers.

Setting and Participants  Outpatient office setting among health care providers.

Main Outcomes and Measures  The scope of independent billing to Medicare for procedures performed by mid-level providers.

Results  In 2012, nurse practitioners and physician assistants billed independently for more than 4 million procedures at our cutoff of 5000 paid claims per procedure. Most (54.8%) of these procedures were performed in the specialty area of dermatology.

Conclusions and Relevance  The findings of this study are relevant to safety and quality of care. Recently, the shortage of primary care clinicians has prompted discussion of widening the scope of practice for mid-level providers. It would be prudent to temper widening the scope of practice of mid-level providers by recognizing that mid-level providers are not solely limited to primary care, and may involve procedures for which they may not have formal training.

Nurse practitioners (NPs) and physician assistants (PAs) are termed mid-level medical providers. They were originally envisioned to be primary care physician extenders, particularly in underserved areas. When NPs or PAs assist a physician, they can enhance productivity and patient care. The passage of the Balanced Budget Act of 1997 by Congress allowed NPs and PAs to bill and be paid independently if they are not practicing “incident to” a physician or in a facility.¹

Since 1997, mid-level providers have grown greatly in number and extended their scope of practice. Most recently, they have been encouraged to practice to “the full scope of their license” to help with health care access in some states.² Mid-level providers typically bill under the physicians they work with when they are supervised.³ On these occasions, the physician is reimbursed at 100% of the Medicare contracted rate. When NPs and PAs bill independently, they are reimbursed at 85% of the Medicare contracted rate (except for nurse anesthetists and nurse midwives, who are reimbursed at 100% of the fee schedule but are not studied herein). These mid-level providers are required to bill independently in all facilities, including hospitals and nursing homes. The only circumstance that allows for independent billing in the office setting is when the supervising physician is not on the premises or when the procedures are distinct unsupervised services (paid at the reduced 85% rate) when the physician in on the premises. This study identifies independent billing to Medicare for procedures performed by mid-level providers in an outpatient office setting.

All direct patient identifiers and provider numbers (Social Security number, zip code, name, and address) were removed before release to us of the database used herein. Therefore, the data are deidentified, and the study was exempt from review by an institutional review board.

We analyzed and extracted data from the 2012 Medicare Physician/Supplier Procedure Summary Master File,⁴ which is a 100% summary of all Part B Carrier and Durable Medical Equipment Regional Contractor claims processed through the Common Working File and stored in the National Claims History Repository. The database is produced annually and is available through the Centers for Medicare & Medicaid Services.

We searched for self-reported Current Procedural Terminology (CPT) codes billed independently by code 50 for NPs and code 97 for PAs in the office setting. We first used a cutoff of 5000 times in a calendar year to highlight the most frequently paid CPT codes. We then focused on codes typically performed by dermatologists.

Some CPT codes were excluded. These were laboratory/pathology (codes 80000x), evaluation and management (codes 90000x), injectable drugs that ordinarily cannot be self-administered (J codes), medical services (M codes), pathology and laboratory codes (P codes), temporary codes (Q codes), private payer codes (S codes), and venipuncture.

The resulting data for CPT codes independently performed and billed by mid-level providers in an office setting more than 5000 times in a calendar year are listed in Table 1. All CPT codes typically used by dermatologists that were independently performed and billed by mid-level providers in the office setting most of the time are listed in Table 2. We used statistical software (SAS version 9.4; SAS Institute Inc) for our data collection.

In 2012, NPs and PAs performed and billed independently for more than 4 million procedures (Table 1) at our cutoff of 5000 paid claims per procedure. Most (54.8%) of these procedures were performed in the specialty area of dermatology. The most commonly performed dermatologic procedures were destruction of premalignant lesions, 2 to 14, which was billed 1 411 541 times, and biopsy of skin lesion, single, which was billed 283 601 times. Procedures performed to destroy or excise malignant lesions totaled 67 019, while those to repair totaled 18 157 for intermediate layered and 8702 for complex closures (Table 2). In addition, 856 363 diagnostic or therapeutic imagings were billed (Table 1).

The breadth and frequency of dermatologic procedures independently performed and billed by mid-level providers are extraordinary. Most of the approximately 2.6 million dermatologic procedures performed in the office setting in 2012 were destruction of premalignant lesions, which requires correct distinction of a premalignant lesion from a benign one. Inappropriate cryotherapy of these lesions may lead to scarring, dyspigmentation, and unnecessary costs. A skin biopsy was independently billed by NPs and PAs more than 400 000 times. Since mid-level providers do not have the same depth of training in diagnosis as dermatologists nor is certification of diagnostic qualifications the same, the concern is the necessity for biopsy to be performed. In addition, punch biopsies of the skin are potentially hazardous because of the risk of arterial or nerve injury. Destruction or excision of malignant lesions and intermediate and complex closures all necessitate detailed knowledge of surgical anatomy to prevent excessive bleeding, denervation, and scarring. Also concerning is the number of independent billings for diagnostic radiology considering the difficulty and liability inherent in their interpretation (Table 1).

Mid-level providers were originally envisioned to be primary care physician extenders to enhance delivery of patient care in tandem with a physician. Recently, the shortage of primary care clinicians has been noted, and the need for widening the scope of practice for mid-level providers has been advocated.^2,5 However, independent practice by mid-level providers in the office setting, as reported herein, is a different situation from the perspective of patient safety and quality of care. Physicians on average complete 10 000 clinical hours in residency compared with between 500 and 900 clinical hours that a doctorate in nursing or a master’s in physician assistance requires.^6,7 Except for phlebotomy, intravenous access, and catheter placement, surgery or invasive procedures are not usually included in this training.

Some of these procedures may have been billed incorrectly, but a cutoff of 5000 paid claims per procedure makes this unlikely. It is also possible that these mid-level providers were billing independently with a physician on the premises, although this seems unlikely because they will be paid at only 85% of the fee schedule instead of reporting incident to and the physician receiving 100% of the fee schedule.

Several actions seem obvious to address this situation. The existence of multiple boards and differing regulations is problematic. If legislators continue to direct that mid-level providers may be recognized as primary care physicians (as in Massachusetts⁸) and allowed to practice medicine independently (as in 22 states and the District of Columbia), they should also mandate a single state medical and nursing board to ensure a consistent standard of care to protect patients.

At a minimum, states should require mandatory reporting of complications by mid-level providers and reporting by physicians who see these complications. In some instances, nursing boards have authorized nursing candidates to perform invasive procedures for which the members of the nursing board were not trained.⁹ Researchers recently noted a large increase in malpractice claims associated with cosmetic laser surgery by mid-level providers.¹⁰ Mandatory physician reporting of office surgery complications in Florida, with cross-matching of malpractice claims, has proven useful in identifying and eliminating dangerous procedures performed in the office setting.¹¹ Such data collection should be supported by mid-level providers because it could put patient safety concerns to rest.

In a study conducted by the American Medical Association in 2008, almost 40% percent of the public mistakenly believed a doctor of nursing was a medical doctor.¹²

Since the public is often unaware of the differences in the qualifications of providers,¹² medical transparency laws that require the training and degree of health care providers to be prominently displayed in all patient encounters would be beneficial to the patient in determining the necessity of the procedure being recommended by an unsupervised mid-level provider.¹³ Finally Congress could consider amending the 1997 Balanced Budget Act to align it with its original intent, by restricting independent Medicare payment of mid-level providers to evaluation and management codes to enhance access to primary care. This action would concentrate mid-level providers in their area of training and greatest need.

Accepted for Publication: June 9, 2014.

Corresponding Author: Mondhipa Ratnarathorn, MD, 3024 Burnet Ave, Cincinnati, OH 45219.

Published Online: August 11, 2014. doi:10.1001/jamadermatol.2014.1773.

Author Contributions: Drs Coldiron and Ratnarathorn had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Administrative, technical, or material support: All authors.

Study supervision: Coldiron.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Christopher Hogan, PhD, Direct Research LLC, assisted with data collection and received compensation for his contributions.