Billing For Nurse Practitioner Services

core0 · Jul 29, 2007

billing for nurse practitioner services -- update 2005: guidelines for nps, physicians, employers, and insurers
do you need a practical review of np billing and reimbursement? carolyn buppert, np, jd, offers guidance in this updated report.
clinical review, medscape, july 2005

this is a good article. a couple of criticisms.

one is that medscape still has the stupid test stuff in there after the ceu has expired.

the other is that given the age of the article there are a few changes in medicare. the first is that after 2003 the np must have a masters degree in nursing not a masters degree from an np school to apply for an npi. this is a subtle distinction but there are still a few schools out there that do not give an msn. i am not sure why the author phrased the article this way since all her other articles specifically state the msn.

the other is that there was a decision by the medicare payors after 2006 that you cannot cobill for an inpatient consult after 2006. this happened after the article was written.

i also recommend her book:

http://www.jbpub.com/catalog/0763733415/

david carpenter, pa-c

Advanced Practice Columnist / Guide · Jul 31, 2007

The other is that given the age of the article there are a few changes in Medicare. The first is that after 2003 the NP must have a masters degree in nursing not a masters degree from an NP school to apply for an NPI. This is a subtle distinction but there are still a few schools out there that do not give an MSN. I am not sure why the author phrased the article this way since all her other articles specifically state the MSN.

Just wondering about your comment here CoreO. I know that there are not just a few schools but actually quite a number of schools that award the degree M.S. for their nurse practitioner programs and not an M.S.N. That does not mean that the program is not nursing focused, it's just that the university awarded the M.S. degree with a specialization in nursing. Schools that award an M.S.N. are those where the degree was conferred by the college or school of nursing of the particular university. I personally work with a graduate of an NP program where the degree is an M.S. instead of an M.S.N. (University of Michigan, Ann Arbor to be specific) and she had no trouble getting an NPI number.

By the way, that Buppert book is an excellent reference. We used it as required text in one of our classes.

core0 · Jul 31, 2007

Just wondering about your comment here CoreO. I know that there are not just a few schools but actually quite a number of schools that award the degree M.S. for their nurse practitioner programs and not an M.S.N. That does not mean that the program is not nursing focused, it's just that the university awarded the M.S. degree with a specialization in nursing. Schools that award an M.S.N. are those where the degree was conferred by the college or school of nursing of the particular university. I personally work with a graduate of an NP program where the degree is an M.S. instead of an M.S.N. (University of Michigan, Ann Arbor to be specific) and she had no trouble getting an NPI number.
By the way, that Buppert book is an excellent reference. We used it as required text in one of our classes.

It depends on when they applied for their UPIN. If it was before 2003 then they could get a UPIN and therefore an NPI. After 2003 if you do not have an MSN Medicare was not supposed to grant a UPIN. Not to say they don't make mistakes but anyone who applied for a NPI or UPIN after 2003 could be in trouble if someone figures it out. Here is the original text:

"(4) Be a nurse practitioner who on or

after January 1, 2003, applies for a

Medicare billing number for the first

time and possesses a master's degree in

nursing and meets the standards for

nurse practitioners in paragraphs

(b)(1)(i) and (b)(1)(ii) of this section."

For the full text:

http://a257.g.akamaitech.net/7/257/2422/13nov20061500/edocket.access.gpo.gov/cfr_2006/octqtr/pdf/42cfr410.75.pdf

Here is the court decision that laid this out:

http://www.hhs.gov/dab/decisions/CR1527.htm

Here is the ACNP comment:

http://www.acnpweb.org/i4a/pages/Index.cfm?pageID=3444

Also the CNS part is somewhat different. It requires:

"and who holds a master's degree in a defined clinical area of nursing"

Although I will note that this concerned an NP that did not have a Masters not about an MSN. My understanding is that this has impacted the Stanford dual PA/NP program. The Davis program is adding additional classes for the MSN. As I understand it the Stanford program is dropping the NP option. Here is the rational:

http://pcap.stanford.edu/program/FNP%20Option%20Change.pdf

Actually looking at what the federal reg says and how a number of schools describe their degrees I would guess that the scenario you describe above is OK. As long as the Masters is from a school of nursing it would appear to meet the criteria. I know of one program that used to give a Master's in Counseling from the Psychology program for their psych NP program and another that gave a Masters in Health Science for the FNP program. Since neither of these were in the school of nursing I would guess that these would not qualify for a Masters in Nursing.

David Carpenter, PA-C

frUABgrad · Feb 10, 2011

David,

I am trying to find info that tells exactly what Medicare and other private insurances reimburse for ACNPs in the office, hospital and assisting in the OR. Do you have any resources for this? Could you also send me a PM so I could ask you some other questions?

Thanks!

core0 · Feb 10, 2011

David,
I am trying to find info that tells exactly what Medicare and other private insurances reimburse for ACNPs in the office, hospital and assisting in the OR. Do you have any resources for this? Could you also send me a PM so I could ask you some other questions?
Thanks!

Two different questions.

Medicare:

Office - 85% of physician fee for the same service (100% for incident to)

Hospital - 85% of physician fee for same service (100% for shared billing)

OR - First assisting is 13.6% of the surgeons fee (85% of the first assist surgeons fee of 16%). It has to be a covered surgery. Take a look at the AAPA brief on first assist for surgery (basically it applies to NPs also)

http://www.aapa.org/advocacy-and-practice-resources/reimbursement/medicare/892-first-assisting-at-surgery

Private insurance is completely different. Its going to depend on the contract that is negotiated with the insurance carrier. Even within a particular insurance carrier may reimburse differently for different policies.

frUABgrad · Feb 10, 2011

thanks!