The Way Things Were
As a hospital trained nurse, it has been my privilege to experience nursing for over five decades. It was quite different 50 years ago when we wore all white – stockings, uniforms, shoes and caps. Back then, we stood up if seated when a doctor entered the room. At that time, all the doctors were men and all the nurses were women. The culture of medicine at that time had almost a religious aura about it, with the doctor as the deity and the nurses as guardian angels who watched over the patients, comforting them and following doctors’ orders.
To illustrate just "how things were", you can listen to a conversation I had with two very senior nurses interviewed for a nurse radio program. It may provide historical context and some fascinating medical lore. Nurses Eileen Keenan and Lynette Juliet were best friends and colleagues from 1935 until their retirement in 2003. Sixty-eight years of nursing service that covers almost 7 decades of change and transformation in nursing.
An Change in the Environment
While there are still remnants of that culture, to some extent today in various medical facilities or hospitals across the country, the medical environment is quite different now due to technology, higher education and the media. Today’s nursing is perceived as a career, where it was once viewed as a calling or vocation. Going back to the 1980s when caps were still parts of the nursing mystique, the profession was perceived as being in service to patients and required dedication to the welfare and care of others. It has been said that nursing attracts individuals of a highly compassionate nature.
With educational requirements as they are today for entering the profession, there is a great emphasis on academic and clinical skills and less emphasis on patient engagement and relationship development skills that there was just a few decades ago. There are more individuals who are entrepreneurial minded entering the field of medicine and nursing, so there are many directions a trained nurse can go in with her/his credentials.
Although the need for well trained, caring nurses is constant, today many nurses wish to strike out on their own and offer private practice services rather than work in acute care or in-patient environments. The medical infrastructure depends on nurses as the hands and heart of healing and nursing is today still the fastest growing medical profession in the country. Another attraction to nursing is that it appears to be recession-proof, which was demonstrated during the latest difficult recession which began in 2008.
Changes in Nurses and Nursing
The average age of nurses today is over 50 years old and many individuals are entering the professional later in life than in years before. The number of males has also significantly increased and continues to grow as salaries for nurses are competitive with other professions and skill sets.
The introduction of holistic nursing, Whole Health nursing and nurse coaching has also opened up other areas of work for nurses as well. There are telephonic nurse coaches, insurance company coaches, and HR coaches in various corporations and hospital. For the nurse who wishes to have their own private practice in any of these holistic fields, clarification around the legal and billings regulations for nurses is critical.
All nurses can work privately in their state, according to the practice guidelines of that state. The state regulations can vary significantly and each nurse should contact their licensing board to identify what is permitted in their location. There are, however, hard and fast rules that apply to all nurses across all states.
No nurse can direct bill for medical services, with the exception of designated APRNs. Below are the chapter and verse references from Medicare regarding nurse billing. Nurse services can be billed under a physician’s license but she/he cannot use their nurse NPI number, which is intended for the physician or institution to use for billing for the service they may provide. There are only four (4) Advanced Practice Nurse credentials that allow for direct billing of insurance: Nurse Practitioners, Nurse Mid-Wives, APR Clinical Nurse Specialist and Nurse Anesthetist.
Non-advanced specialty trained nurses cannot direct bill Medicare for any services, and most commercial payers closely follow Medicare. According to Medicare nurses are not a recognized billing provider class. They can only bill "incident to" a physician's service using 99211 for a patient visit if they meet the requirements to do so and only under the physician's NPI number, not their own. There is absolutely no debate about this. Please see below from the Medicare Claims Processing Manual, chapter and verse cited.
Medicare Claims Processing Manual
Chapter 12 - Physicians/Non-physician Practitioners
30.6.4 - Evaluation and Management (E/M) Services Furnished Incident
to Physician’s Service by Non-physician Practitioners (Rev. 1, 10-01-03)
When evaluation and management services are furnished incident to a physician’s service by a non-physician practitioner, the physician may bill the CPT code that describes the evaluation and management service furnished.
When evaluation and management services are furnished incident to a physician’s service by a non-physician employee of the physician, not as part of a physician service, the physician bills code 99211 for the service.
A physician is not precluded from billing under the “incident to” provision for services provided by employees whose services cannot be paid for directly under the Medicare program. Employees of the physician may provide services incident to the physician’s service, but the physician alone is permitted to bill.
Services provided by employees as “incident to” are covered when they meet all the requirements for "incident to" and are medically necessary for the individual needs of the patient.
More About Private Practice
In upcoming articles, we will explore various specialties that nurses can be trained for which will allow them an additional scope of practice, and credentials to be able to bill for services in private practice.