For evaluation/management and consultation services, Medicare pays psychiatric CNSs (as well as other CNSs, nurse practitioners, and physician assistants) 85% of 80% the physician rate for a service, as listed in the Medicare physician fee schedule for the current year. The patient pays 20% of the fee as a copayment.
Full Answer
What are the Medicare billing options for nurse practitioners?
Medicare Billing Option #1: Direct Billing Nurse Practitioners (NP), Clinical Nurse Specialists (CNS), and Physician Assistants (PA) may apply for individual provider numbers for direct billing purposes. All covered services rendered may be billed using the NPPs direct provider number.
Can a CNS furnish services billed under all levels of codes?
Also, if authorized under the scope of his or her State license, a CNS may furnish services billed under all levels of evaluation and management codes and diagnostic tests if furnished in collaboration with a physician.
Can an NPP bill for services provided to a physician?
Rather than bill directly for services provided as outlined in Option #1; an NPP may provide services "incident to" a physicians professional services and bill accordingly for those services.
What is an example of a CNS service?
Examples of the types of services that a CNS may furnish include services that traditionally have been reserved for physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting x-rays, and other activities that involve an independent evaluation or treatment of the patient’s condition.
Can a CNS 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).
What codes can a nurse bill for?
What codes can an RN bill for? Insurance reimbursement coding is based on the American Medical Association CPT2 coding system. Under that system, the only Evaluation and Management (E/M) code that a Registered Nurse can bill to is 99211.
Can a PA bill Medicare?
The Medicare program designates a limited number of services that can be performed only by physicians. High-performing private practices and clinics may bill for services provided by PAs using PA NPI numbers, accepting Medicare reimbursement at 85 percent of the physician charge.
Can a nurse practitioner bill a consult?
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).
Can you bill for nurse phone calls?
Answer: An RN can provide Telephone Triage calls when the RN is overseen by a physician, NP or PA. The Telephone Triage calls can be billed using CPT codes 98966-98968; the rendering requirement provider information on the claim must reflect the overseeing provider's NPI and/or Medicaid Provider ID number.
Can you bill a nurse visit for a blood pressure check?
Can you bill CPT Code 99211 for a blood pressure check by the nurse? ANSWER: You may bill CPT code 99211 for a blood pressure evaluation for an established patient whose physician requested a follow-up visit to check blood pressure. CPT code 99211 does not require the presence of the physician.
Can a nurse practitioner bill a 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.
Can a fellow bill for services?
A fellow who is not fully licensed or is not authorized under the institution's bylaws to bill for services is not permitted to bill for moonlighting services under the MPFS. Medicaid, TRICARE and private payers have different rules regarding the permissibility of billing by fellows in approved and unapproved programs.
Can a PA bill for a consult?
Medicare has also clearly stated that PAs may perform consultations in any practice setting. The Medicare Carriers Manual Transmittal 1725 (Sept. 27, 2001) states: “Non-physician practitioners, e.g., nurse practitioners, certified nurse mid-wives or physician assistants, may request a consultation.
What are non-physician services?
Nurse practitioners, clinical nurse specialists, and physician assistants are health care providers who practice either in collaboration with or under the supervision of a physician. We refer to them as non-physician practitioners.
What can doctors do that nurse practitioners Cannot?
For NPs who work in restricted states, they cannot prescribe, diagnose, or treat patients without physician oversight. Doctors are able to prescribe, diagnose, and treat patients in all 50 states and Washington, D.C.
How do you bill a nurse practitioner service?
Applying Physician Billing Rules to NPsServices must be medically necessary;Services must have been provided as billed, as supported by the medical record;The clinician providing the service must have a Medicare provider number;The entity seeking payment must submit a claim, appropriately completed;More items...•
Can a RN Bill 99212?
A: That depends entirely on what was done and documented. In most cases, the visit would be a level one new patient visit (99201), level two established patient visit (99212), or nurse visit (99211), since only one body area is examined, and the history and/or medical decision-making are straightforward.
Can a RN Bill 99213?
Expert. If the nurse is a NP, they could bill any level.
Can a nurse Bill 99202?
To report, use 99202. The 99201 – 99205 code set is reported for E/M services rendered to New Patients in the Office or Other Outpatient settings....Be Aware of These Changes in 2021 If You Bill Office/Other Outpatient E&M Codes.CodeNumber and Complexity of Problems Addressed at the EncounterN/A99202 9921225 more rows•Oct 29, 2020
What can nurses do independently?
10 ideas for a self-employed RNProvide independent care. You might provide individual in-home care for patients as a self-employed nurse. ... Work as a nursing consultant. ... Develop products for nurses. ... Provide health counseling. ... Provide fitness advising. ... Teach health courses. ... Work as a freelance writer. ... Work as nurse contractor.More items...•
Qualifications
In order to furnish covered CNS services, a CNS must meet the conditions as follows:
Covered Services
Coverage is limited to the services a CNS is legally authorized to perform in accordance with State law (or State regulatory mechanism provided by State law).
Types of CNS Services that May be Covered
State law or regulations governing a CNS' scope of practice in the State in which the services are furnished applies. Carriers must develop a list of covered services based on the State scope of practice.
Services Otherwise Excluded from Coverage
A CNS' services are not covered if they are otherwise excluded from coverage even though a CNS may be authorized by State law to perform them.
Collaboration
Collaboration is a process in which a CNS works with one or more physicians (MD/DO) to deliver health care services within the scope of the CNS' professional expertise with medical direction and appropriate supervision as required by the law of the State in which the services are furnished.
Direct Billing and Payment
A CNS may bill directly and receive direct payment for their services.
Can a CNS bill Medicare?
A CNS may bill Medicare for a service provided by another individual, under certain circumstances. Medicare Part B covers services and supplies provided and billed "incident to" a CNS's services. "Incident to" means that the services or supplies are furnished as an integral, although incidental, part of the CNSs' personal professional services in the course of diagnosis or treatment of an injury or illness. [ 16]
Can a CNS be billed by a physician?
In specific circumstances, a CNS' service could be billed under a physician's provider number. That is, a service performed by a CNS could be billed incident to a physician's service, and the practice would receive 100% percent of the physician fee schedule rate for the service. (See "Payment" section for more information regarding the payment rates for CNSs.)
What is Medicare incident to billing?
Medicare Billing Option #2: "Incident to" Billing. Rather than bill directly for services provided as outlined in Option #1; an NPP may provide services "incident to" a physicians professional services and bill accordingly for those services. Even though an NPP may be licensed under state law to perform a specific medical procedure ...
Can an NPP be licensed under state law?
Even though an NPP may be licensed under state law to perform a specific medical procedure and may be able to perform that medical procedure without physician supervision and have the service separately covered and paid by Medicare (as defined in Billing Option #1); all criteria must be met for those services to be covered as "incident to".
What are the categories of CNS services?
CNS services generally fall into 3 categories -- evaluation and management, consultation, and psychotherapy. For a description of these services and the essential components for each level of service within these broad categories, read the corresponding sections of Current Procedural Terminology[ 8] for the current year.
What is Medicare PIN?
The numbers are the Provider Identification Number (PIN) also referred to as the "provider number" and the Unique Physician Identification Number (UPIN), now also referred to as the National Provider Identifier (NPI). A UPIN or NPI is a nationally assigned alphanumeric identifier to be reported with services that have been referred or ordered and equipment ordered. An individual always will have only one UPIN/NPI, but may have varying PINs, depending on the site of service.
Does Medicare require providers to keep current with the rules?
As a condition of participation with the program, Medicare requires its providers to keep current with the program rules. The healthcare provider who does not follow the rules may encounter denied payments, reduced payments, demand for repayment of funds already paid, and investigation and charges of billing abuse or fraud. Medicare's rules are voluminous, and the rules applicable to CNSs are not located in one place. In addition, CMS changes the rules fairly frequently. This article contains only the basic rules applicable to CNSs as of the date written. Updated information is available through periodic newsletters from Medicare Carriers, the Carriers' Web sites, the CMS, and Local Medical Review Policies (LMRP) Web sites, and classes at carriers' offices.
Does Medicare pay for E/M services?
Advise physicians to use CPT codes (level 1 of HCPCS) to code physician services, including evaluation and management services. Medicare will pay for E/M services for specific non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS) and certified nurse midwife (CNM)) whose Medicare benefit permits them to bill these services. A physician assistant (PA) may also provide a physician service, however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non-physician practitioners. The service provided must be medically necessary and the service must be within the scope of practice for a non-physician practitioner in the State in which he/she practices. Do not pay for CPT evaluation and management codes billed by physical therapists in independent practice or by occupational therapists in independent practice.
Can a hospital E/M be billed under a PIN number?
When a hospital inpatient/ hospital outpatient or emergency department E/M is shared between a physician and an NPP from the same group practice and the physician provides any face-to-face portion of the E/M encounter with the patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number. However, if there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate physician fee schedule rate based on the UPIN/PIN entered on the claim.
Do carriers have to bill the highest level of visit and consultation codes?
Carriers must advise physicians that to bill the highest levels of visit and consultation codes, the services furnished must meet the definition of the code (e.g., to bill a Level 5 new patient visit, the history must meet CPT’s definition of a comprehensive history).
Qualifications
Covered Services
- Coverage is limited to the services a CNS is legally authorized to perform in accordance with State law (or State regulatory mechanism provided by State law). 1. The services of a CNS may be covered under Part B if all of the following conditions are met: 2. They are the types of services that are considered as physician's services if furnished by ...
Types of CNS Services That May Be Covered
- State law or regulations governing a CNS' scope of practice in the State in which the services are furnished applies. Carriers must develop a list of covered services based on the State scope of practice. Examples of the types of services that a CNS may furnish include services that traditionally have been reserved for physicians, such as physical examinations, minor surgery, se…
Services Otherwise Excluded from Coverage
- A CNS' services are not covered if they are otherwise excluded from coverage even though a CNS may be authorized by State law to perform them. For example, the Medicare law excludes from coverage routine foot care and routine physical checkups and services that are not reasonable and necessary for diagnosis or treatment of an illness or injury or to improve the function of a m…
Collaboration
- Collaboration is a process in which a CNS works with one or more physicians (MD/DO) to deliver health care services within the scope of the CNS' professional expertise with medical direction and appropriate supervision as required by the law of the State in which the services are furnished. In the absence of State law governing collaboration, collaboration is to be evidenced …
Resources
- CMS Internet Only Manual (IOM), Publication 00-02, Medicare Benefit Policy Manual, Chapter 15, Section 210