Clinical Nurse Specialist (CNS)

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Qualifications

In order to furnish covered CNS services, a CNS must meet the conditions as follows:

  1. Be a registered nurse who is currently licensed to practice in the State where he or she practices and be authorized to furnish the services of a clinical nurse specialist in accordance with State law;
  2. Have a master's degree in a defined clinical area of nursing from an accredited educational institution; and
  3. Be certified as a clinical nurse specialist by a recognized national certifying body that has established standards for CNSs.

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).

  • The services of a CNS may be covered under Part B if all of the following conditions are met:
  • They are the types of services that are considered as physician's services if furnished by an MD/DO;
  • They are furnished by a person who meets the CNS qualifications;
  • The CNS is legally authorized to furnish the services in the State in which they are performed;
  • They are furnished in collaboration with an MD/DO as required by State law; and
  • They are not otherwise excluded from coverage because of one of the statutory exclusions.

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, 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 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.

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 malformed body member. Therefore, these services are precluded from coverage even though they may be within a CNS' scope of practice under State law.

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 by the CNS documenting his or her scope of practice and indicating the relationships that the CNS has with physicians to deal with issues outside the CNS' scope of practice.

The collaborating physician does not need to be present with the CNS when the services are furnished or to make an independent evaluation of each patient who is seen by the CNS.

Direct Billing and Payment

A CNS may bill directly and receive direct payment for their services.

Assignment Requirement

Assignment is required for the service to be covered.

Resources

Last Updated Wed, 12 Feb 2020 15:05:18 +0000