Advanced Practice Registered Nurses (APRNs)

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For information on how to enroll in Medicare, visit Advanced Practice Nonphysician Practitioners.  

Certified Registered Nurse Anesthetists (CRNAs)

Qualifications & Criteria

You must:

Service Requirements

You must meet these requirements:

  • You’re legally authorized to perform anesthesia and related care in the state where you furnish the services.
  • Unless the state where you practice opted out of supervision requirements, you must:
    • Administer anesthesia in a hospital under the operating practitioner’s supervision or under an anesthesiologist’s immediate supervision. Immediate supervision means an anesthesiologist is physically located within the same area as the CRNA and can provide immediate hands-on intervention, if needed.
    • Administer anesthesia in acritical access hospital (CAH) or ambulatory surgical center (ASC) under the operating practitioner’s supervision.

Billing Guidelines

  • You may bill for your services using:
    • Your NPI
    • The hospital, physician, group practice, or ASC NPI where you have an employment or contractual relationship
  • Anesthesia time is the continuous period that:
    • Begins when you’ve prepared the patient for anesthesia services in the operating room or equivalent area
    • Ends when you place the patient safely under post-operative care
  • You may add blocks of anesthesia time if you furnish continuous anesthesia care within the time periods around an interruption
  • Anesthesia billing modifiers include:
    • QS: Monitored anesthesia care service
Note:
A physician or a qualified non-physician anesthetist may use the QS modifier for informational purposes. You must report actual anesthesia time and 1 payment modifier on the claim.
  • QY: Medical direction of 1 qualified non-physician anesthetist service with medical direction by a physician
  • QZ: CRNA service without medical direction by a physician
  • QX: Qualified non-physician anesthetist service with medical direction by a physician

Payment Guidelines

  • We pay only on an assignment basis
  • We pay services at 100% under the Physician Fee Schedule (PFS) or in accordance with the level of supervision provided
  • Under the Anesthesia Fee Schedule based on applicable locality adjusted anesthesia Conversion Factor (CF) multiplied by the sum of allowable base and time units; 1 anesthesia time unit = 15 minutes anesthesia time
  • The patient may be responsible for paying you for a Part B copayment, deductible, or coinsurance
  • We may pay you directly or pay another individual or entity where you have an employment or contractual arrangement

More Information

Nurse Practitioners (NPs)

Qualifications & Criteria

You must be a licensed registered professional nurse authorized by the state where you provide NP services according to state law and meet 1 of these requirements:

  • Got Medicare billing privileges for the first time on or after January 1, 2003, and:
    • Are NP certified by a recognized national certifying body with established NP standards
    • Have a master’s degree in nursing or a Doctor of Nursing Practice (DNP) doctoral degree
  • Got Medicare NP-billing privileges the first time before January 1, 2003, and are NP-certified by a recognized national certifying body with established NP standards
  • Got Medicare NP-billing privileges the first time before January 1, 2001

Service Requirements

You must meet these requirements:

  • You’re legally authorized to practice medicine in the state where you furnish
  • Services are reasonable and
  • You furnish your professional services in collaboration with a Collaboration happens when NPs work with 1 or more physicians to deliver health care services within their professional scope of expertise and provide medical direction and appropriate supervision required by state law where they perform services.

Coverage & Documentation Guidelines

  • We consider the services physician services if a medical doctor or Doctor of Osteopathy furnished them.
  • We may cover assistant-at-surgery services you furnish personally.
  • You may have services and supplies provided incident to your personal professional
  • You may certify patient eligibility under the Medicare home health benefit and oversee their plan of care. You may bill codes G0179, G0180, and G0181.
  • You may review and verify (sign and date), rather than re-document, notes in a patient’s medical record made by:
    • Physicians
    • Residents
    • Nurses
    • Medical, PA, or APRN students
    • Other medical team members

These notes can include information documenting your presence and service participation.

Billing Guidelines

  • You may:
    • Use your NPI to bill your services
    • Let an employer or contractor use your NPI to bill your reassigned
  • To bill for incident to services:
    • Use your NPI, if you’re a supervising physician or nonphysician practitioner
    • If you provide services incident to another physician’s or nonphysician practitioner’s services, the supervising physician or nonphysician practitioner must use their NPI to bill the incident to professional services you provide
  • Report only the AS modifier on the claim form when you bill assistant-at-surgery services.
  • We apply reasonable and necessary standards to every billing request. This limits our payments to covered services that address and treat patient complaints and symptoms. Services must meet specific medical necessity statutes, regulations, manual requirements, and National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). For each billed service, note specific signs, symptoms, or patient complaints that make each service reasonable and necessary.

Payment Guidelines

  • We pay only on an assignment basis.
  • You can’t charge a patient more than the amounts permitted under 42 CFR 424.55. If a patient pays more for a service than the assignment payment limits, you must refund the excess amount.
  • We pay your personal professional services at 80% of the lesser of the actual charge or 85% of the amount a physician gets under the Physician Fee Schedule(PFS) when furnished outside a hospital or SNF setting.
  • We pay you directly for assistant-at-surgery services at 85% of 16% of the amount a physician gets under the PFS.
  • We pay you for “incident to” services provided by auxiliary personnel (outside a hospital or SNF setting) at 85% of the amount a physician gets under the PFS.
  • We pay your professional services only when:
    • You personally perform the services.
    • There aren't any facility or other provider charges. We don’t pay any amount to other professionals for providing services.

More Information

Clinical Nurse Specialists (CNSs)

Qualifications & Criteria

You must:

  • Be a registered nurse currently licensed in the state where you practice and be authorized to provide CNS services according to state law
  • Have a Doctor of Nursing Practice (DNP) or master’s degree in a defined clinical nursing area from an accredited educational institution
  • Be CNS-certified by a recognized national certifying body with established CNS standards

Service Requirements

You must meet these requirements:

  • You’re legally authorized to practice medicine in the state where you furnish the
  • Services are reasonable and
  • We consider the services physician services if a medical doctor or Doctor of Osteopathy provided Physician services include professional patient services a physician performs, including diagnosis, therapy, surgery, consultation, and care plan oversight.
  • You furnish your professional services in collaboration with a Collaboration happens when CNSs work with 1 or more physicians to deliver health care services within their professional scope of expertise and provide medical direction and appropriate supervision required by state law where they perform services.

Coverage & Documentation Guidelines

  • You may have services and supplies provided incident to your personal professional
  • You may furnish assistant-at-surgery
  • You may certify patient-eligibility under the Medicare home health benefit and oversee their plan of care. You may bill codes G0179, G0180, and G0181.
  • You may review and verify (sign and date), rather than re-document, notes in a patient’s medical record made by:
    • Physicians
    • Residents
    • Nurses
    • Medical, PA, or APRN students
    • Other medical team members

These notes can include information documenting your presence and service participation.

Billing Guidelines

  • You may:
    • Use your NPI to bill your services
    • Let an employer or contractor use your NPI to bill your reassigned
  • To bill for incident to services:
    • Use your NPI, if you’re a supervising physician or nonphysician practitioner.
    • If you provide services incident to another physician’s or nonphysician practitioner’s services, the supervising physician or nonphysician practitioner must use their NPI to bill the incident to professional services you provide.
  • Report only the AS modifier on the claim form when you bill assistant-at-surgery services.

Payment Guidelines

  • We pay only on an assignment basis.
  • You can’t charge a patient more than the amounts permitted under 42 CFR 424.55. If a patient pays more for a service than the assignment payment limits, you must refund the excess amount.
  • We pay your personal professional services at 80% of the lesser of the actual charge or 85% of the amount a physician gets under the Physician Fee Schedule(PFS) when furnished outside a hospital or SNF setting.
  • We pay you directly for assistant-at-surgery services at 85% of 16% of the amount a physician gets under the PFS.
  • We pay your incident to services provided outside a hospital or SNF setting at 85% of the amount a physician gets under the PFS.
  • When you bill your services in the hospital setting (inpatient and outpatient), we unbundle the payment and make the payment directly to you under the PFS.
  • We pay your professional services only when:
    • You personally perform the services.
    • There aren't any facility or other provider charges. We don’t pay any amount to other professionals for providing services.

More Information

Certified Nurse-Midwives (CNMs)

Qualifications & Criteria

You must:

  • Be a registered nurse legally authorized to practice in the state where you provide services
  • Have successfully completed a nurse-midwives study and clinical experience program accredited by an approved U.S. Department of Education accrediting body
  • Be certified as a nurse-midwife by the American College of Nurse-Midwives or the American College of Nurse-Midwives Certification Council

Service Requirements

You must meet these requirements:

  • Services are reasonable and necessary
  • Services are within the scope of practice authorized by the state where they’re provided and we would otherwise cover them if provided by a physician or as incident to a physician’s service
  • We consider the services physician services if a medical doctor or Doctor of Osteopathy provided them
  • You provide services without physician supervision and without association with a physician or other health care provider, unless otherwise required under state law

Coverage & Documentation Guidelines

  • You may have services and supplies provided incident to your personal professional services
  • We cover services in all settings, including:
    • Birthing centers
    • Clinics
    • Hospitals
    • CNM offices
    • Patients’ homes
  • You may review and verify (sign and date), rather than re-document, notes in a patient’s medical record made by:
    • Physicians
    • Residents
    • Nurses
    • Medical, PA, or APRN students
    • Other medical team members

These notes can include information documenting your presence and service participation.

Billing Guidelines

  • You may:
    • Use your NPI and specialty code 42 to bill your services
    • Let an employer or contractor use your NPI and specialty code 42 to bill your reassigned
  • To bill for incident to services:
    • Use your NPI, if you’re a supervising physician or nonphysician practitioner.
    • If you provide services incident to another physician’s or nonphysician practitioner’s services, the supervising physician or nonphysician practitioner must use their NPI to bill the incident to professional services you provide.
  • Use billing modifier 52 (reduced services) to report the billing provider didn’t provide all covered global services Don’t use when billing split or shared evaluation and management visits.

Payment Guidelines

  • We pay only on an assignment basis.
  • You can’t charge a patient more than the amounts permitted under 42 CFR 424.55. If a patient pays more for a service than the assignment payment limits, you must refund the excess amount.
  • We pay services at 80% of the lesser of the actual charge or 100% of the amount a physician gets under the Physician Fee Schedule(PFS).
  • We pay covered drugs and biologicals provided incident to your services according to Part B drug and biological payment methodology.
  • We pay your incident to services provided outside a hospital or SNF setting at 100% of the amount a physician gets under the PFS.
  • We pay your covered clinical diagnostic lab services according to the clinical lab fee schedule
  • When you bill directly for services in the hospital setting (inpatient and outpatient), we unbundle the payment and make the payment to you under the PFS.
  • When you provide most of a global service and call in a physician to provide a portion of the care or when the physician provides most of the service and calls you in, we base payment on the portion of the global fee that we would pay to the billing practitioner. You and physicians use reduced service modifiers to report they didn’t provide all covered global allowance services.

More Information

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Page Last Modified:
11/06/2023 10:11 AM
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