PA,NP, CNS, CNM Billing Guide, REF-EDO-0020 - NHIC, Corp.

Physician Assistant (PA), Nurse Practitioner (NP), Clinical Nurse Specialist (CNS),
and Certified Nurse-Midwife (CNM) Billing Guide
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Relationship with Physician
Most States have licensure and other requirements applicable to CNMs. For example, some
require that the CNM have an arrangement with a physician for the referral of the patient in the
event a problem develops that requires medical attention. Others may require that the CNM
function under the general supervision of a physician. Although these and similar State
requirements must be met in order for the CNM to provide Medicare covered care, they have no
effect on the CNM’s right to personally bill for and receive direct Medicare payment. That is,
billing does not have to flow through a physician or facility.
INCIDENT-TO SERVICES
Medicare pays for services and supplies (including drug and biologicals which are not usually
self-administered) that are furnished incident to a physician’s or other practitioner’s services. A
practitioner includes a physician assistant, nurse practitioner, clinical nurse specialist, and
certified nurse-midwife. For purposes of this section physician also means
practitioner/PA,NP,CNS, CNM. Incident to a physician’s professional services means that the
services or supplies are furnished as an integral, although incidental, part of the physician’s
personal professional services in the course of diagnosis or treatment of an injury or illness.
Services must be performed under the physician’s direct supervision. Direct supervision means
the physician must be present in the office suite and immediately available to furnish assistance
and direction throughout the performance of the procedure.
To be covered incident to the services of a physician, services and supplies must be:
• An integral, although incidental, part of the physician’s professional service;
• Commonly rendered without charge or included in the physician’s bill;
• Of a type that are commonly furnished in physician’s offices or clinics;
• Furnished by the physician or by auxiliary personnel under the physician’s direct
supervision.
It is within Medicare benefit categories that a PA, NP, CNS, or CNM may enroll in the Medicare
program and provide services without direct supervision and have the service covered.
However, these specialties may opt to provide services incident to an MD or DO. It is not within
Medicare benefit categories for auxiliary personnel such as registered nurses or licensed practical
nurses to enroll in the Medicare program or provide services without direct supervision. Such
auxiliary personnel may only provide services under the incident to guidelines.
Auxiliary personnel is defined as any individual who is acting under the supervision of a
physician, regardless of whether the individual is an employee, leased employee, or independent
contractor of the physician, or of the legal entity that employs or contracts with the physician.
Where a physician supervises auxiliary personnel to assist him/her in rendering services to
patients and includes the charges for their services in his/her own bills, the services of such
personnel are considered incident to the physician’s service if there is a physician’s service
rendered to which the services of such personnel are an incidental part and there is direct
supervision by the physician.
NHIC, Corp. 14 July 2010
REF-EDO-0020 Version 1..0
The controlled version of this document resides on the NHIC Quality Portal (SharePoint). Any other version or copy, either electronic
or paper, is uncontrolled and must be destroyed when it has served its purpose.