Medicare Legislation

Medicare Update

AANP, 2013

Effective with the passage of the Balanced Budget Act of 1997, all NPs, CNSs and PAs must have their own billing number in order to bill Medicare, even if they are employed and even if their employer has always billed for their services using the employer's billing number. Initially, payment for NPs, CNSs, and PAs was based on PIN numbers provided by CMS. Now it is based on NPI numbers, which can be obtained by nurse practitioners for identification and billing purposes.

Billing Directions

NPs are expected to submit claims to the Part B carrier under their own NPI number. Previously when NPs rendered services they entered their carrier assigned PIN number on the CMS 1500 billing form. Now that identifier must be an NPI. NPs may assign their numbers to a group practice for purposes of billing. There are no limitations on CPT codes as long as they are recognized by Medicare as reimbursable codes for physician services. Evaluation and Management Guidelines should be consulted to insure accurate coding. When NPs are ordering or referring services, they must use their NPI to order or refer. Medicare will not pay for referral/ordered services or items unless the name and NPI number of the referring entity is on the claim. Only physicians, nurse practitioners, clinical nurse specialists, physician assistants and certified nurse midwives are allowed to refer/order services or items for beneficiaries.

Duplicate Payments

No separate payment may be made to the nurse practitioner when a facility or other provider payment or charge is made for the same professional services. This includes hospitals, SNFs, NFs, comprehensive outpatient rehabilitation facilities (CORF), ASCs, community mental health centers (CMHC), rural health centers (RHC) or federally qualified health centers (FQHC).

Qualifications For NPs Seeking Reimbursement For Services To Medicare Patients

In order to obtain a Medicare NPI number for the first time, nurse practitioners must be graduates of masters, postmasters, or DNP programs, nationally certified, and recognized in their states as nurse practitioners.

Ordering Physical Therapy And Occupational Therapy Services

Under the provisions of this statue, nurse practitioners are authorized to order physical therapy and occupational therapy for Medicare patients under their care.

Ordering And Performing Diagnostic Tests

Nurse Practitioners are authorized to order diagnostic tests for patients under their care. They may also be reimbursed for performing diagnostic and interpreting tests they are authorized to perform. Physician supervision is not required.

Ordering And Performing Sigmoidoscopies And Colonoscopies

Nurse Practitioners are authorized to order and perform screening colonoscopies and screening and diagnostic sigmoidoscopies on Medicare patients.

Durable Medical Equipment

A face to face encounter must be conducted and documented prior to ordering durable medical equipment (DME).

Telemedicine Services

Nurse practitioners are authorized to serve as both primary care providers and consultants in the utilization of telemedicine for the management of Medicare patients in federally designated Health Manpower Shortage Areas.

Medicare Managed Care

Under the statute and regulation for Medicare Managed Care, nurse practitioners may serve as PCPs on Medicare Managed Care Panels. They may also appeal claims in behalf of their patients. Non-discrimination language in the legislation prevents carriers from excluding nurse practitioners from provider panels and allows them to represent patients in appeals for rejected claims.

"Incident to"

At the present time, the rules for "incident to" services are unchanged and continue to be limited to services providedstrictly as a follow up to the provider's plan of care. "Incident to" billing is limited to the office setting. If "incident to" services are provided by a nurse practitioner or a clinical nurse specialist, the physician must still be on site, and the visit cannot be with a new patient or with an old patient with a new problem. Note that under the BBA, when staff provide services "incident to" an NP's services, the NP may bill for those services at the 85% rate. The same rule for physician applies to NPs, i.e. the services are limited to the follow up plan of care of the NP and the NP must be on site to bill for the services.

Shared Visits in Hospitals

Nurse practitioners who have their own billing number and provide shared visits with physicians in hospitals may bill for services at 100% as long as the physician has also seen the patient the same day in a "face to face" encounter. Billing will take place under the physician billing number.

Attending in Home Health and Hospice Care

Nurse practitioners are authorized to receive reimbursement for serving as "attending physicians" in hospice and home health care. While this does not yet allow nurse practitioners to order/authorize hospice care or home health care, nurse practitioners are authorized to re-certify patient eligibility for hospice care.

Face to Face Requirement to Order Home Health

In order for patients to obtain home health care services a face to face encounter with an eligible provider must occur within 90 days of the start of service. A nurse practitioner may conduct that encounter, but a physician must still document its occurrence.

Hospital Admitting Physical Examinations

The physician counter signature requirement for hospital admitting physical examinations conducted by nurse practitioners has been eliminated.

Supervising Procedures in Outpatient Settings

Nurse practitioners may directly supervise all hospital outpatient therapeutic services in both hospital and satellite sites that they may perform themselves. (This does not include pulmonary, cardiovascular and intensive cardiovascular rehabilitation services.) Direct supervision in this case means the nurse practitioner must be present on the same campus and immediately available to furnish assistance and direction throughout the performance of the procedure.