CMS Nurse Practitioner and Physician Assistant Reimbursement Guidelines

CMS GUIDELINES

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Nurse Practitioners

The guidelines for Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), and Certified Nurse-Midwives (CNMs) from the Centers for Medicare & Medicaid Services (CMS) are comprehensive and cover various aspects such as qualifications, service requirements, billing, and payment guidelines.

1. Nurse Practitioners (NPs):

  • Qualifications: NPs must be licensed registered professional nurses authorized by the state to provide NP services. They should be NP certified by a recognized national certifying body with established NP standards and hold a master’s degree in nursing or a Doctor of Nursing Practice (DNP) degree.
  • Service Requirements: NPs are legally authorized to practice medicine in the state where they furnish services. They must furnish their professional services in collaboration with one or more physicians, following the requirements of state law.
  • Billing and Payment Guidelines: NPs can use their National Provider Identifier (NPI) to bill for services. Services must meet medical necessity statutes, regulations, manual requirements, and coverage determinations. Payments for their professional services are typically at 80% of the lesser of the actual charge or 85% of the amount a physician receives under the Physician Fee Schedule (PFS) when furnished outside a hospital or SNF setting.

2. Clinical Nurse Specialists (CNSs):

  • Qualifications: CNSs must be licensed registered nurses, authorized to provide CNS services according to state law, with a DNP or master’s degree in a defined clinical nursing area. They also need to be CNS-certified by a recognized national certifying body.
  • Service Requirements: CNSs are legally authorized to practice medicine in the state where they provide services. They must work in collaboration with one or more physicians to deliver healthcare services.
  • Billing and Payment Guidelines: CNSs use their NPI for billing services, and similar to NPs, their payment follows the Physician Fee Schedule. They receive 80% of the lesser of the actual charge or 85% of the amount a physician receives under the PFS when furnished outside a hospital or SNF setting.

3. Certified Nurse-Midwives (CNMs):

  • Qualifications: CNMs must be registered nurses legally authorized to practice in the state where they provide services. They must have completed an accredited nurse-midwives study and clinical experience program and be certified by a recognized body.
  • Service Requirements: CNMs provide services that are within the scope of practice authorized by the state. They may provide services without physician supervision unless otherwise required by state law.
  • Billing and Payment Guidelines: CNMs use their NPI and specialty codes to bill services. They are paid at 80% of the lesser of the actual charge or 100% of the amount a physician receives under the PFS for services outside a hospital or SNF setting. They also receive payment for incident services and clinical diagnostic lab services according to specific schedules.

These guidelines are part of the CMS’s effort to ensure that advanced practice registered nurses provide quality care within their scope of practice and are appropriately compensated for their services. For more detailed information, it's recommended to refer directly to the CMS documentation and specific state laws, as they can provide more specific information tailored to different regions and practice settings.

Physician Assistants
The Centers for Medicare & Medicaid Services (CMS) have set specific guidelines for Physician Assistants (PAs) regarding qualifications, service requirements, coverage and documentation, and billing guidelines:

1. Qualifications & Criteria:

  • PAs must be licensed by the state where they practice.
  • They need to have graduated from a PA educational program accredited by the Accreditation Review Commission on Education for the Physician Assistant or its predecessor agencies.
  • PAs must have passed the national certification exam administered by the National Commission on Certification of Physician Assistants.

2. Service Requirements:

  • PAs should be legally authorized to practice medicine in the state where they furnish services.
  • Their services are considered physician services if a medical doctor or Doctor of Osteopathy provided them.
  • PAs must provide services under physician supervision.

3. Coverage & Documentation Guidelines:

  • CMS covers services only when furnished according to state law and scope-of-practice rules. PAs have flexibility to meet the statutory physician supervision requirement in collaboration with physicians and forming partnerships if it’s according to state scope of practice laws.
  • PAs may provide assistant-at-surgery services.
  • They may certify patient eligibility under the Medicare home health benefit and oversee their plan of care, and bill codes G0179, G0180, and G0181.

4. Billing Guidelines:

  • PAs may bill CMS directly for their services. For services provided before January 1, 2022, CMS paid the employer of the PA, whether they were employed under a W-2 employer-employee relationship or as an independent contractor who received an IRS 1099 reflecting the relationship.

These guidelines ensure that PAs provide quality care within their scope of practice and receive appropriate compensation for their services. For more detailed information, it's advisable to refer directly to CMS documentation and specific state laws, as they provide more specific information tailored to different regions and practice settings.

Assistant Surgeons
The CMS guidelines for assistant surgeons include specific billing and reimbursement rules:

1. Reimbursement for Assistant Surgeons:

  • Services rendered by an assistant surgeon are reimbursed at 16% of the maximum allowance for the primary procedure.
  • For non-physician providers (Physician Assistants, Nurse Practitioners, or Clinical Nurse Specialists) serving as assistant surgeons, reimbursement is at 85% of 16% (i.e., 13.6%) of the Medicare Physician Fee Schedule Database (MPFSDB) amount.
  • Assistant surgeons must be board-certified or highly qualified as skilled surgeons, and licensed as physicians in the state where services are provided.

2. Billing Guidelines:

  • Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon), or 82 (when a qualified resident surgeon is not available) is used by physicians to bill for assistant surgery services.
  • Modifier AS is used to indicate that a non-physician provider served as the assistant at surgery.
  • Separate reimbursement is not allowed for hospital-employed Physician Assistants, Nurse Practitioners, or Nurse Midwives. Their reimbursement for a covered procedure is 13.6% of the maximum allowed for the procedure.

3. Requirements for Co-Surgeons and Team Surgery:

  • Reimbursement for co-surgeons is 120% of the maximum allowance for the primary procedure, divided equally between the co-surgeons.
  • Reimbursement for team surgery is determined on an individual consideration basis.
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