Nurse Practitioner (NP) - JE Part A
Nurse Practitioner (NP)
View the below related information on this page.
- Covered Services
- Types of NP Services that May be Covered
- Services Otherwise Excluded from Coverage
- Direct Billing and Payment
- Assignment Requirement
To furnish and bill Medicare for covered NP services, an NP must be a registered professional nurse authorized by the State in which the services are furnished to practice as an NP in accordance with State law and must also meet one of the below criteria.
- Obtained Medicare billing privileges as an NP for first time on/after January 1, 2003, is certified by a recognized national certifying body, and has a master’s or doctoral degree in nursing
- Obtained Medicare billing privileges as an NP for first time before January 1, 2003 and is certified by a recognized national certifying body
- Obtained Medicare billing privileges as an NP for first time before January 1, 2001
Coverage is limited to the services an NP is legally authorized to perform in accordance with State law (or State regulatory mechanism established by State law).
- The services of an NP may be covered under Part B if all of the following conditions are met:
- They are the type that are considered physician's services if furnished by a doctor of medicine or osteopathy (MD/DO);
- They are performed by a person who meets the definition of an NP;
- The NP is legally authorized to perform the services in the State in which they are performed;
- They are performed in collaboration with an MD/DO; and
- They are not otherwise precluded from coverage because of one of the statutory exclusions.
Types of NP Services That May Be Covered
State law or regulation governing an NP's scope of practice in the State in which the services are performed applies. Consider developing a list of covered services based on the State scope of practice. Examples of the types of services that NP's may furnish include services that traditionally have been reserved to 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. Also, if authorized under the scope of their State license, NPs may furnish services billed under all levels of evaluation and management codes and diagnostic tests if furnished in collaboration with a physician.
Services Otherwise Excluded From Coverage
The NP services may not be covered if they are otherwise excluded from coverage even though an NP may be authorized by State law to perform them. For example, the Medicare law excludes from coverage routine foot care, routine physical checkups, and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Therefore, these services are precluded from coverage even though they may be within an NP's scope of practice under State law.
Collaboration is a process in which an NP works with one or more physicians (MD/DO) 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. In the absence of State law governing collaboration, collaboration is to be evidenced by NPs documenting their scope of practice and indicating the relationships that they have with physicians to deal with issues outside their scope of practice.
The collaborating physician does not need to be present with the NP when the services are furnished or to make an independent evaluation of each patient who is seen by the NP.
Direct Billing and Payment
Direct billing and payment for NP services may be made to the NP.
Assignment is mandatory.
- CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 200
Last Updated Tue, 20 Dec 2022 15:32:28 +0000