NPs should adopt the following practices to ensure their claims are reimbursed appropriately and promptly in order to stay up-to-date on each health plan's claims reimbursement requirements: NPs should know their contractual rights and responsibilities contained in provider contracts with health plans and third party payors.
Full Answer
How are nurse practitioners reimbursed under the Medicare physician fee schedule?
Nurse practitioners are reimbursed from the Medicare physician fee schedule (MPFS) at 85 percent of the rate allowed when a physician performs the service, subject to a 20 percent coinsurance.
Does a nurse practitioner have to be present for Medicare billing?
For Medicare billing purposes, when billing under the nurse practitioner benefit (and not as an “incident to” service), the collaborating physician does not need to be present with the nurse practitioner when the services are furnished. Supervision requirements are set by state law.
How are nurse practitioners and physician assistants billed?
As will be further discussed below, the services of nurse practitioners and physician assistants may be billed by a physician practice using the name and Medicare billing number of these providers.
What practices should a nurse practitioner adopt to ensure claims are reimbursed?
NPs should adopt the following practices to ensure their claims are reimbursed appropriately and promptly in order to stay up-to-date on each health plan's claims reimbursement requirements: NPs should know their contractual rights and responsibilities contained in provider contracts with health plans and third party payors.
Can an NP bill Medicare?
March 1, 2020, Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Physician Assistants (PAs) can certify Medicare patient home health benefit eligibility and oversee patient care plans (page 4).
How do you bill for nurse practitioner services basics?
The services must be billed under the NP's provider number, unless the entity doing the billing is following Medicare's rules on "shared visits." If those rules are followed, the services may be billed under the physician's provider number.
Why are billing and coding skills essential for family nurse practitioners?
Billing and Coding Breakdown Helps Nurses Recognize the Realities of Reimbursement. Understanding correct coding strategies is an important skill that affects billing and reimbursement for value-based cancer care. Meeting the requirements for complete and accurate documentation is critical to support healthcare claims.
Why are nurse practitioners reimbursed less?
Why do NPs get reimbursed less than medical doctors for the same care? The 85% reimbursement policy is supported by the rationale that physicians have higher student loans, pay practice overhead cost, have higher malpractice premiums, and care for more complex patients (MedPAC, 2002).
Can a nurse practitioner Bill 99214?
Yes, NPs can bill for 99214 and 99215 visits with the following caution: Beware in states where the scope of NP practice is not specifically defined to include comprehensive evaluations.
What modifier does a nurse practitioner use?
MODIFIER FOR INCIDENT-TO SERVICES Though HCPCS specifies “nurse practitioner” in the descriptor, modifier SA may also be used when billing for services provided by physician assistants, clinical nurse specialists, or other advanced practice professionals specified in a payer's policy.
Can nurse Practitioners Bill consultation codes?
Guru. Yes they can. When requested by a physician or other appropriate source, a consultation may be provided by a physician or qualified nonphysician practitioner (NPP).
How do you bill for a nurse visit?
A: The 99211 E/M visit is a nurse visit and should be used only by a medical assistant or a nurse when performing services such as wound checks, dressing changes or suture removal. CPT code 99211 should never be billed for physician, physician assistant or nurse practitioner services.
How do you code a primary care visit?
Data show that family physicians choose 99213 for about 61 percent of visits with established Medicare patients and choose 99214 only about 23 percent of the time for the same type of visit. So 99213 must be the correct code to use for a “routine” visit, right?
How do I get Medicare reimbursement?
How to Get Reimbursed From Medicare. To get reimbursement, you must send in a completed claim form and an itemized bill that supports your claim. It includes detailed instructions for submitting your request. You can fill it out on your computer and print it out.
What does it reimburse the NP compared to the physician?
States reimburse nurse practitioners at anywhere from 75% to 100% of the physician rate. This means that unlike Medicare, some state Medicaid plans treat services provided by nurse practitioners equally to those provided by physicians. In fact, most states reimburse NPs at 100% the rate of MDs.
What are the common issues in billing and reimbursement?
Simple ErrorsIncorrect patient information. Sex, name, DOB, insurance ID number, etc.Incorrect provider information. Address, name, contact information, etc.Incorrect Insurance provider information. ... Incorrect codes. ... Mismatched medical codes. ... Leaving out codes altogether for procedures or diagnoses.Duplicate Billing.
When is NP payment effective?
Payment for NP services is effective on the date of service, that is, on or after January 1, 1998, and payment is made on an assignment-related basis only.
When did Medicare start covering nurse practitioners?
Medicare rules – Nurse Practitioner (NP) Services. Effective for services rendered after January 1 , 1998, any individual who is participating under the Medicare program as a nurse practitioner (NP) for the first time ever, may have his or her professional services covered if he or she meets the qualifications listed below, ...
What is covered under Part B?
1. General. The services of an NP may be covered under Part B if all of the following conditions are met:
When did physician assistants get Medicare?
Physician assistants who received Medicare billing numbers prior to January 1, 1998 are exempt from meeting these qualifications. As was the case with nurse practitioners, physician assistants who are applying for their Medicare billing numbers at the present time must be licensed in the state in which they intend to practice ...
What is Medicare collaboration?
Medicare defines “collaboration” as being a process in which a nurse practitioner works with one or more physicians to deliver health care services, with medical direction and appropriate supervision as required by the law of the state in which the services are furnished. Where a state does not have a law or regulations that govern collaboration, ...
Does Medicare cover physician assistants?
Medicare coverage is limited to services that a physician assistant is legally permitted to perform in the state in which he or she is practicing. In addition to the foregoing, the following requirements must be met for the services of a physician assistant to be covered under Medicare:
Is a nurse practitioner covered by a physician?
Coverage for the services of nurse practitioners is limited to the services that a nurse practitioner is legally authorized to perform in accordance with state law and regulations. In addition, all of the following conditions must be met for the services of a nurse practitioner to be covered when billed by a physician or physician group utilizing ...
Can a nurse practitioner bill Medicare?
Nurse practitioners may be employees or independent contractors of a physician or physician group in order to allow the physician or group to bill for their services. Nurse practitioners are also permitted to bill independently or to form their own entities to bill and receive payment from Medicare.
Can a physician assistant bill for a nurse practitioner?
Physician assistants may not bill and receive payment on their own or in a group of physician assistants. As is the case with nurse practitioners, payment for physician assistant services is based on the lower of either 80 percent of the actual charge or 85 percent of the physician fee schedule amount. The foregoing provides a basic summary of ...
What is the role of a NP in a nursing facility?
Medicare requires that the initial visit (history and physical), for the purpose of certifying that the patient requires skilled care, must be performed by a physician.
What is the role of NP?
The NP role, and services that are reimbursed within that role, are influenced by several factors. Medicare policies are complex and are modified frequently. Interpretation of those policies by Part B Carriers varies from state to state. Individual state laws have significant differences regarding scope of NP practice.
What certifications do NPs need to be certified by?
Medicare requires NPs to be certified by a recognized national certifying body such as American Nurses Credentialing Center (ANCC) in order to become a Medicare provider. An article by Carolyn Buppert [3] provides a list of other approved certifying bodies. In addition, effective January 1, 2003, individuals are required to possess a Master's degree from an accredited program.
What is POS in medical billing?
Information that must be submitted (or provided to billing service) accurately includes place of service (POS) and diagnoses. POS varies depending on the type of facility the patient is in. POS could be a skilled nursing facility (SNF) when the patient is medically certified for skilled care under Medicare Part A. An individual qualifies for skilled care within 30 days of a 3-day (minimum) hospital stay, and when they have the potential for improvement with rehabilitation, or the need for skilled nursing care. Some hospitals have "swing" beds that are equivalent to SNF beds and are sometimes referred to as "transitional" beds. POS could also be a nonskilled facility for basic care, or an assisted living unit for domiciliary care.
What are the guidelines for medical history?
The Guidelines describe the types (problem-focused, detailed, comprehensive) and elements of history, as well as the types of examination and required elements for each type. The Guidelines also describe the 4 levels of medical decision-making and the 3 elements that determine the level of complexity.
What are the 3 levels of medical decision making?
The 3 levels differ in the extent of history and physical examination and in the complexity of medical decision-making. A code of 99311 requires any 2 of the 3 elements; a problem-focused interval history, a problem-focused examination, and medical decision-making that is straight-forward or of low complexity.
What is a comprehensive nursing assessment?
Comprehensive Nursing Facility Assessments are used for new patients being admitted to a facility (99303), as well as for established patients at the time of a yearly history and physical (99301), or on development of a new problem resulting in a permanent change of status (99302-03). All 3 levels of service require 3 key components: history, physical examination, and medical decision-making. Counseling and/or coordination of care are provided as needed depending on the nature of the problem and the needs of the patient/family. The 3 levels differ in the extent of the history and physical exam components and in the complexity of medical decision-making and time spent.
What should the NP's documentation reflect?
If diagnostic tests are ordered, the NP's documentation should reflect the rationale for the tests; more importantly, if the NP's findings indicate a patient concern and the NP chooses to observe the patient further, the documentation must reflect the reasoning for not immediately ordering diagnostic tests.
How many primary care providers will be needed in the US in 2016?
According to the American Academy of Family Physicians, the shortfall is expected to exceed 29,000 physicians by 2016 ...
What documentation should be included in a medical plan?
At a minimum, proper documentation should include the following: An assessment, history, and physical exam based on the patient's symptoms and complaints. A plan of care for the patient.
Why is documentation important in healthcare?
Documentation. Every healthcare provider knows the importance of documentation relative to effective patient care and treatment. Making other providers aware of the patient's status, preventing mistakes, and ensuring accountability are just a few of the benefits.
When are CPT codes revised?
CPT codes are revised on January 1 of each year, so it is imperative that NPs track changes annually and determine appropriate descriptors for E/M services so that the proper level of service is billed. The use of obsolete CPT codes or invalid descriptors will result in denied claims for reimbursement.
When was the ICd 10 re-enacted?
When President Obama signed the Protecting Access to Medicare Act of 2014 on April 1, 2014, the ICD-10 implementation date was moved back 1 year to October 1, 2015.
What is E/M billing?
It is important to know that the level of E/M services is based on the extent and complexity of the history obtained from the patient (problem focused, expanded problem focus, detailed, or comprehensive), physical exam, as well as medical decision making, which includes documentation of the patient's diagnosis, treatment options, test data (X-ray findings, ECG results), risk of complications, morbidity, or mortality. Billing for these services is based on the extent of the history, physical exam, and medical decision making involved in the patient encounter. In the event counseling services are provided to the patient, the NP must remember that billing is based on the amount of time spent counseling the patient and coordinating the care; patient counseling in an office setting is billed on face-to-face time, while billing for counseling in the hospital is based on the amount of time addressing the patient's issues both in a face-to-face interaction and when coordinating follow-up actions on the hospital unit.
How much is Medicare reimbursement for nurse practitioners?
Nurse practitioners are reimbursed from the Medicare Physician Fee Schedule (MPFS) at 85 percent of the rate allowed when a physician performs the service, subject to a 20 percent coinsurance. See https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf , section 120.
Does Medicare require additional documentation?
Medicare may require additional documentation, when applicable, to validate key information contained within the enrollment application (e.g., name change, tax identification number, proof of citizenship) or to address specific issues that could adversely affect a practitioner’s potential eligibility for enrollment (e.g., adverse legal actions, financial relationships).
What is Medicare claim "you"?
“You” refers to AAs in this section. For complete details on coverage, billing, and payment for non-physician anesthetists, refer to Sections 50 and 140 of Chapter 12 of the Medicare Claims
What is reasonable and necessary?
Reasonable and necessary is a standard applied to every request for payment (bill) which limits Medicare payment to covered services addressing and treating the patient’s complaints and symptoms. Services must meet specific medical necessity requirements contained in the statutes, regulations, manuals, and defined by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). For every service billed, you must indicate any specific signs, symptoms, or patient complaints that make each service reasonable and necessary.