info@mentalhealthbillingservice.com
Mental Health Billing Services (MHBS) handles billing for psychiatric mental health nurse practitioners across all 50 states.
Most billers get it wrong, whether a Medicare visit bills under your own NPI at 85% of the fee schedule or qualifies as incident-to at 100%—and keep the supervision and documentation audit-ready.
We route medication-management and psychotherapy claims to the right payer or carve-out, handle telepsychiatry, and structure billing around your state’s scope-of-practice rules.
PMHNP billing is the coding and claim process for psychiatric mental health nurse practitioners that determines how psychiatric services are reimbursed based on provider type, supervision relationships, and state scope-of-practice rules. It uses the same clinical codes as psychiatry E/M for medication management, psychotherapy add-ons, and 90792 but adds a layer unique to nurse practitioners: Medicare pays 85% of the Physician Fee Schedule under the NP’s own NPI, or 100% when a visit qualifies as incident-to a supervising physician. State scope-of-practice rules determine how and under whose NPI a PMHNP can bill.
Under their own NPI, PMHNPs are paid 85% of the Medicare fee schedule. The same established-patient follow-up visit, billed correctly as incident-to under a supervising physician, pays 100%. Getting this decision right—and only when the rules truly allow it—is the single biggest revenue-and-compliance lever in psychiatric nurse practitioner billing. Most generic billers default to one rate across all visits, either leaving money on the table or creating audit exposure.
In full-practice-authority states a PMHNP bills independently under their own NPI without a collaborative agreement. In reduced or restricted practice states, a collaborative or supervisory agreement is required, which shapes whether incident-to billing is even available and how your claims must be structured. This is why PMHNP billing cannot be treated as a one-size-fits-all service.
PMHNPs bill the same E/M and psychotherapy add-on codes as psychiatrists. We cover that coding in detail on our psychiatry billing page; this page is exclusively about the nurse-practitioner reimbursement structure, incident-to determination, scope-of-practice billing, and dual-panel routing that make PMHNP billing distinct. (View Psychiatry Billing for Coding (Interlink here)
Problem 1: Everything Billed at 85% (Money Left on the Table)
A practice with a supervising physician bills every PMHNP Medicare visit under the NP's own NPI at 85%, never capturing the 100% incident-to rate on the established-patient follow-ups that legitimately qualify. The 15% gap compounds across every qualifying Medicare visit. For a practice seeing 20 Medicare patients daily, this can represent tens of thousands of dollars in lost annual revenue.
Leaving the incident-to 15% you're owed on the table means your practice is effectively subsidizing Medicare with revenue that could be funding staff, technology, or practice growth. Over a full year, the cumulative loss from not capturing incident-to on every eligible encounter is substantial.
We identify which encounters genuinely meet incident-to criteria and bill them at 100%—and bill the rest correctly at 85%—with the supervision documentation to back it up. Our encounter-level review ensures every visit receives the correct reimbursement rate based on its specific circumstances.
Problem 2: Incident-To Billed Where It Doesn’t Apply (Audit Risk)
The opposite error is worse: billing incident-to on a new patient, a new problem, or without a qualifying supervising physician immediately available. Split/shared and incident-to billing errors are a documented government audit and False Claims Act focus because of the 15% uplift. The OIG has specifically targeted incident-to billing as a high-risk area.
Improper incident-to billing can trigger Medicare audits, recoupment demands, penalties, and in severe cases, False Claims Act liability. The financial and reputational damage from an audit finding can far exceed the 15% gain you were attempting to capture. Your supervision documentation must be audit-ready at all times.
We apply incident-to only to established-patient, no-new-problem, office (POS 11) encounters with documented supervision, and use the 2026 audio-video supervision allowance correctly. New patients and new problems bill own-NPI at 85%. Our coders verify every incident-to claim against the Medicare Benefit Policy Manual, Ch. 15, §60 requirements.
Problem 3: Scope-of-Practice Mismatch in Restricted States
In reduced or restricted practice states, billing structured as if the PMHNP had full practice authority—or using a lapsed or improperly documented collaborative agreement—produces denials and compliance exposure. Many billers don't understand that state scope-of-practice rules directly affect how claims must be submitted and under whose NPI.
Denied claims, delayed payments, and potential scope-of-practice violations can disrupt cash flow and create regulatory scrutiny. In restricted states, billing without proper supervisory documentation can result in claims being rejected or audited.
We structure billing to the state's scope rules and the collaborative agreement on file, and flag when the agreement or supervising-physician relationship affects claim routing. We verify each state's current AANP designation and apply the correct billing structure accordingly.
Problem 4: Single-Panel Enrollment Leaves Therapy Unpaid
A PMHNP credentialed only on the medical panel cannot get the psychotherapy add-on paid through the behavioral health carve-out—so combined medication-management and therapy visits lose the psychotherapy revenue entirely. The E/M portion may pay, but the psychotherapy add-on is denied because the provider isn't credentialed with the behavioral health entity.
Every combined visit with a psychotherapy add-on is partially unpaid. For practices seeing many patients requiring both medication management and therapy, this represents substantial lost revenue that could otherwise be collected.
We confirm dual-panel enrollment (medical + carve-out) and route each component correctly—E/M to the medical payer, psychotherapy add-on to the behavioral health carve-out. Credentialing itself is handled by our credentialing team.
Problem 5: Aging AR and Unresolved Denials
Denied claims sit in aging AR with no one working them systematically. Incident-to denials, scope-of-practice rejections, and carve-out routing issues are particularly common for PMHNPs. Without dedicated denial management, these claims often age out or get written off.
Unresolved denials represent cash flow gaps and revenue leakage. The longer a claim sits in AR, the less likely it is to be collected. Many practices leave substantial revenue uncollected simply because they lack the expertise to appeal PMHNP-specific denials.
We work aging AR, rework denials, and appeal (including parity appeals) with an incident-to compliance lens. Our denial management approach addresses the root causes of PMHNP denials.
Encounter-level review of which Medicare visits bill under the PMHNP’s own NPI at 85% of the Physician Fee Schedule and which qualify as incident-to at 100%, with supervision and plan-of-care documentation kept audit-ready. We verify that incident-to claims meet all CMS requirements: established patient with no new problem, office setting (POS 11), physician-initiated plan of care, and supervising physician immediately available (now including 2026 audio-video allowance). This incident-to determination is the single most important revenue decision we make for your practice.
For PMHNPs working in facility settings (hospitals, skilled nursing facilities, etc.), correct split/shared billing determination—distinct from and mutually exclusive with incident-to—driven entirely by place of service. Split/shared visits are the facility-setting counterpart to incident-to, and the two billing methods cannot be used interchangeably. POS 11 means incident-to applies; any other POS means split/shared rules govern shared physician/NP encounters. We never conflate the two.
Billing structured to the state’s FPA / reduced/restricted status and the collaborative agreement on file, including multi-state telepsychiatry caseloads. We verify each state’s current AANP State Practice Environment designation and apply the correct billing framework. Full Practice Authority means independent own-NPI billing; Reduced Practice requires a collaborative agreement; Restricted Practice requires a supervisory agreement. This scope-of-practice structuring ensures your claims comply with both state regulations and payer requirements.
Capture of the E/M level (99202–99205 for new patients; 99211–99215 for established) and the psychotherapy add-on (90833 for 16–37 minutes, 90836 for 38–52 minutes, 90838 for 53+ minutes) on combined visits, routed to the correct medical payer or behavioral health carve-out. This combined-visit routing ensures the E/M adjudicates on the medical side while the psychotherapy add-on pays through Optum, Carelon, Evernorth, or other MBHOs. (Detailed coding mechanics: see our psychiatry billing page.)
POS 10/02 and modifier discipline aligned to the current 2026 permanence rules for behavioral health telehealth. PMHNP telepsychiatry is permanently covered under Medicare for behavioral health services. We apply the correct modifiers (95, 93, or FQ) and place-of-service codes to ensure telepsychiatry claims are paid correctly across all payers.
Aging AR worked systematically, denials reworked and appealed (including MHPAEA-aligned parity appeals), with an incident-to compliance lens applied to every denial review. Deep denial methodology addresses the specific reasons PMHNP claims get denied—incident-to eligibility questions, scope-of-practice mismatches, carve-out routing errors, and documentation deficiencies.
The incident-to decision and supervision documentation are too high-risk to leave to a generalist biller who doesn’t understand nurse-practitioner reimbursement.
Medicare pays NPs/PMHNPs 85% of the Physician Fee Schedule under their own NPI—a longstanding rule from the Balanced Budget Act of 1997, applied regardless of state practice authority. This means that when you bill under your own NPI, you receive 85% of what Medicare would pay a physician for the same service. This 85% rate applies whether you’re in a Full Practice Authority state or a restricted state; state scope doesn’t affect the Medicare reimbursement percentage—it affects the billing structure and whether you need a collaborative agreement, but the 85% rate applies universally when billing under your own NPI.
Incident-to billing allows an established-patient follow-up visit to be billed under a supervising physician’s NPI at 100% of the Medicare fee schedule. All of the following conditions must be met:
When all these conditions are satisfied, you bill the visit under the physician’s NPI at 100%, capturing the 15% difference from the own-NPI rate.
New patients, new problems, and facility settings cannot bill incident-to. These encounters must bill under the PMHNP’s own NPI at 85% of the fee schedule (facility settings use split/shared billing instead of incident-to). Specifically:
CMS now allows the ‘immediately available’ direct-supervision requirement to be met via real-time, synchronous audio-video communication—a meaningful change for multi-site and partly-remote practices. This means the supervising physician doesn’t need to be physically in the same office suite; they can be immediately available through real-time audio-video connection. This 2026 update significantly expands the practical applicability of incident-to billing for practices with multiple locations or hybrid work arrangements. Our billers apply this 2026 audio-video supervision allowance correctly to maximize your incident-to opportunities while maintaining compliance.
Incident-to is a Medicare construct. Many commercial payers prohibit incident-to billing entirely or have their own rules that differ from Medicare’s. Never assume incident-to applies to commercial plans. We verify each payer’s incident-to policy per contract and apply their specific requirements. UnitedHealthcare, Anthem, Cigna, Aetna, and other commercial carriers may have their own incident-to rules, and some prohibit it entirely. We never present incident-to as universally available.
In facility settings (hospitals, skilled nursing facilities, etc.), split/shared billing—not incident-to—governs shared physician/NP encounters. Place of service decides which applies. Split/shared visits involve both the physician and the NP providing substantive portions of the visit, with billing based on who performed the substantive portion. Split/shared billing and incident-to are mutually exclusive—you cannot use incident-to in a facility setting, and you cannot use split/shared in an office setting. We never conflate the two billing methods.
Own-NPI vs incident-to
85% / 100% capture
Supervision documentation
2026 audio-video supervision
Scope-of-practice structure
Carve-out routing
Pricing
Mental Health Billing Services operates on a percentage-of-collections model with no hidden fees. Your first step is a free PMHNP billing audit to identify whether you’re leaving the incident-to 15% on the table or carrying audit risk.
Top 3 reasons your ABA claims are rejected.
Start without upfront costs
Understand your revenue opportunities
We get paid when you get paid (alignment of incentives)
Not a call center; consistent point of contact
AAPC/AHIMA-certified coders
Audit-ready documentation
| Item | Rule |
|---|---|
|
Own-NPI Medicare rate |
85% of the Physician Fee Schedule (Balanced Budget Act of 1997) |
|
Incident-to rate |
100% (established patient, no new problem, POS 11, physician-initiated plan, immediate supervision available) |
|
New patient / new problem |
Must bill own-NPI at 85%—cannot be incident-to |
|
Facility setting |
Split/shared applies—not incident-to (POS determines which applies) |
|
2026 supervision update |
‘Immediately available’ may be met via synchronous real-time audio-video |
|
Commercial payers |
Incident-to varies by payer—many prohibit it; verify per contract |
|
Taxonomy code |
363LP0808X |
|
Certification |
ANCC PMHNP-BC |
|
FPA vs reduced/restricted |
Consult current AANP State Practice Environment; non-FPA needs collaborative/supervisory agreement |
|
DEA registration |
Required to prescribe controlled substances (scope-dependent in restricted states) |
|
Telepsychiatry |
POS 10/02, modifiers 95/93/FQ; permanently covered under Medicare for BH |
Not sure if you’re leaving the incident-to 15% on the table—or billing it where you shouldn’t?
MHBS provides PMHNP billing services across all 50 states, with expertise tailored to each state’s scope-of-practice framework and Medicaid MCO routing requirements. Geography matters for PMHNP billing not just because of payer variation, but because scope-of-practice status fundamentally changes how your claims must be structured. We group states by practice-authority status to ensure your billing matches your state’s requirements.
| State | Scope Status | Key Billing Consideration |
|---|---|---|
|
California |
Restricted |
Supervisory agreement required; structure billing accordingly; incident-to more commonly relevant with supervisory relationship |
|
Texas |
Restricted |
Supervisory agreement required; incident-to more commonly relevant; Medicaid MCO routing varies by region |
|
New York |
Reduced |
Collaborative agreement required; structure billing accordingly; verify collaborative agreement documentation |
|
Florida |
Restricted |
Supervisory agreement required; incident-to more commonly relevant; Medicare + Medicaid routing |
|
Georgia |
Restricted |
Supervisory agreement required; incident-to more commonly relevant; verify supervision documentation |
|
Tennessee |
Restricted |
Supervisory agreement required; incident-to more commonly relevant; state-specific MCO routing |
|
Arizona |
Full Practice Authority |
Bill independently under own NPI; incident-to optional where physician relationship exists; independent practice |
|
Illinois |
Reduced |
Collaborative agreement required; structure billing accordingly; verify agreement on file |
|
Ohio |
Reduced |
Collaborative agreement required; structure billing accordingly; incident-to available with collaboration |
|
Pennsylvania |
Reduced |
Collaborative agreement required; structure billing accordingly; multi-state telepsychiatry considerations |
|
North Carolina |
Reduced |
Collaborative agreement required; structure billing accordingly; verify collaborative agreement documentation |
|
Washington |
Full Practice Authority |
Bill independently under own NPI; incident-to optional where physician relationship exists; full independent practice |
|
New Jersey |
Reduced |
Collaborative agreement required; structure billing accordingly; incident-to available with collaboration |
|
Massachusetts |
Reduced |
Collaborative agreement required; structure billing accordingly; Medicaid MCO routing variation |
|
Virginia |
Reduced |
Collaborative agreement required; structure billing accordingly; verify agreement on file |
|
Colorado |
Full Practice Authority |
Bill independently under own NPI; incident-to optional where physician relationship exists; independent practice |
|
South Carolina |
Restricted |
Supervisory agreement required; incident-to more commonly relevant; verify supervision documentation |
Dual-panel routing: E/M visits adjudicate on the medical side, while psychotherapy benefits flow through Optum Behavioral Health. Confirm PMHNP credentialing on both panels with taxonomy code 363LP0808X. Incident-to policies vary by plan—verify per contract. Optum Behavioral Health manages behavioral health benefits not only for UnitedHealthcare but also for some non-UHC plans as a third-party administrator. Our billing captures the E/M component on the medical side and the psychotherapy add-on through Optum's behavioral health carve-out.
Clinical management via Carelon Behavioral Health (formerly Beacon Health Options). Psychotherapy add-ons route through the behavioral health carve-out. Ensure the PMHNP's taxonomy code (363LP0808X) and ANCC PMHNP-BC certification are correctly registered with both medical and BH panels. Carelon manages behavioral health benefits for Anthem and various Medicaid carve-outs across multiple states.
Carve-out for BH services through Evernorth Behavioral Health. Combined visits require proper split-routing to ensure both components are paid—E/M on the medical side, psychotherapy add-on through Evernorth. Incident-to is Medicare-specific; Cigna commercial plans have their own rules. We verify Cigna's incident-to policy and apply their specific requirements.
Confirm NP credentialing + incident-to policy per plan. Behavioral health services route through Aetna Behavioral Health. Verify the PMHNP is credentialed for both medical E/M and psychotherapy services. Aetna's incident-to policy may differ from Medicare; we verify per contract.
Medicare is where the 85% vs incident-to 100% rules directly apply. MAC-administered with regional variation. Incident-to requires established patient, no new problem, POS 11, physician-initiated plan, and supervision (with 2026 audio-video allowance). We apply Medicare's incident-to rules rigorously and maintain supervision documentation audit-ready. The Balanced Budget Act of 1997 established the 85% rule that governs Medicare payment to NPs.
Scope-of-practice + MCO routing variation by state. State-specific requirements apply based on each state's Medicaid program and MCO structure. Certification (ANCC PMHNP-BC) and taxonomy alignment (363LP0808X) are critical for claim acceptance. We verify each state's Medicaid requirements and route claims accordingly. State Medicaid programs often follow Medicare's incident-to rules but may have their own variations; we verify per state.
Sometimes. Incident-to lets an established-patient follow-up be billed under a supervising physician's NPI at 100% of the Medicare fee schedule instead of the 85% paid under the PMHNP's own NPI. It applies only to office visits (POS 11), only when the physician set up the plan of care and is immediately available, and only when there's no new problem. New patients and new problems must bill under the PMHNP's own NPI at 85%.
Medicare pays NPs/PMHNPs 85% of the Physician Fee Schedule when billing under their own NPI. This is a longstanding rule from the Balanced Budget Act of 1997 that applies regardless of state practice authority. The 85% rate applies to all Medicare services billed under the PMHNP's own NPI.
An established patient with no new problem, seen in an office setting (POS 11), where the physician established the plan of care and is immediately available (2026 update: immediate availability can be met via synchronous audio-video). All conditions must be met simultaneously for incident-to to apply.
No. New patients must be billed under the PMHNP's own NPI at 85%. Incident-to applies only to established patients with no new problem. A patient's first visit to the practice cannot be incident-to regardless of circumstances.
CMS now allows the 'immediately available' direct-supervision requirement to be met via synchronous real-time audio-video, not only physical presence. This is a meaningful change for multi-site and partly-remote practices that previously couldn't meet the physical presence requirement.
Incident-to applies to office settings (POS 11) and bills at 100% under a physician's NPI when all conditions are met. Split/shared billing applies to facility settings and is mutually exclusive with incident-to. Place of service decides which applies—POS 11 means incident-to; any other POS means split/shared rules apply.
Yes. The 85% rule applies regardless of state practice authority. Full Practice Authority affects whether a collaborative agreement is required, not the Medicare reimbursement rate. Even in FPA states, Medicare pays 85% under your own NPI.
In reduced or restricted practice states, yes. Full Practice Authority states do not require one. Consult the current AANP State Practice Environment map for your state's status. The collaborative agreement must be properly documented to ensure claims are accepted.
Incident-to is a Medicare construct. Many commercial payers prohibit incident-to billing entirely or have their own rules that differ from Medicare's. Never assume incident-to applies to commercial plans. We verify each payer's incident-to policy per contract and apply their specific requirements.
PMHNPs bill the E/M code for medication management (99202–99205 or 99211–99215) and add the psychotherapy add-on code (90833 for 16–37 minutes, 90836 for 38–52 minutes, or 90838 for 53+ minutes). The E/M is routed to the medical payer and the add-on through the behavioral health carve-out (Optum, Carelon, Evernorth, etc.). (Detailed coding mechanics: see our psychiatry billing page.)
Yes. Single-panel enrollment leaves the psychotherapy add-on unpaid. Dual-panel enrollment (medical + behavioral health carve-out) is required for combined visits to be fully reimbursed. Credentialing must include both the medical panel and the behavioral health carve-out.
Yes. Telepsychiatry for behavioral health is permanently covered under Medicare for nurse practitioners. POS 10/02 and modifiers (95, 93, or FQ) must be correctly applied. Telehealth for behavioral health was made permanent under Medicare, and this applies to PMHNPs as well.
The PMHNP taxonomy code is 363LP0808X. This taxonomy must be correctly registered on your NPI and used in credentialing and claims. It identifies you specifically as a psychiatric/mental health nurse practitioner to payers.
ANCC PMHNP-BC (Psychiatric-Mental Health Nurse Practitioner Board Certified). This certification is required for panel enrollment and must be maintained. Payers verify certification during credentialing.
PMHNPs prescribe controlled substances and need DEA registration. This is scope-dependent in restricted states—some restricted states may limit or condition prescriptive authority. DEA registration is required for any PMHNP prescribing controlled substances regardless of state.
Percentage-of-collections with no setup or software fees. Free billing audit before any commitment. No long-term contracts. We get paid when you get paid. Contact us for specific rates.
Most PMHNP practices are either leaving the incident-to 15% on the table or billing it where the rules don’t allow. Our audit tells you which—in under 48 hours.
Simplifying mental health billing with accurate claims, faster reimbursements, and seamless revenue cycle management.
info@mentalhealthbillingservice.com
(860) 500-1471
403, Port Washington Road
