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Medicare Part B 101 Manual

Nonphysician Practitioners

There are many nonphysician practitioner types, e.g., physician assistants, certified registered nurse anesthetists, nurse practitioners, etc., whose services are recognized for reimbursement under the Medicare Program. Depending upon the nonphysician practitioner type, payment is provided directly to the practitioner or to his/her employer.

The following general guidelines apply for nonphysician practitioner services.

  • They must be licensed by the state in which they render services.
  • If the state doesn’t license a specific nonphysician practitioner type, other education, and/or clinical experience may be required.
  • Services that may be billed to Medicare must be for services that their license covers and be for services covered by the Medicare Part B program.
  • They may only submit claims on an assigned basis.
  • They may be assigned his/her own Provider Identification Number (PIN) and submit claims to Medicare under his/her PIN under certain conditions.
  • Whether the nonphysician practitioner is assigned a PIN and will use it in reporting his/her service under the PIN is dependent upon the practitioner type and where the services are rendered, e.g., in a HPSA, physician’s office, etc.
  • Provisions of the Medicare Program will override state licensure.

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Direct Billing/Payment for NPP Services Furnished to Inpatients and Outpatients

Nurse practitioners (NP), clinical nurse specialists (CNS), and physician assistants (PA) are authorized to bill Medicare carriers directly for their professional services when furnished to hospital patients, both inpatients and outpatients. The employer of a PA, rather than the hospital, must bill the carrier for their professional services when furnished to hospital patients. Hospitals should not bill for the professional services of a PA, unless the PA is employed by the hospital.

The professional services of NPs and CNSs furnished to hospital inpatients and outpatients may be billed directly by the NP or CNS to the carrier under their respective NPI.

The employer of a PA may bill the carrier directly for the professional services of the PA furnished to hospital inpatients and outpatients under the PA’s NPI number.

Hospitals may bill the carrier for the professional services of an NP or a CNS furnished to hospital inpatients and outpatients when payment for the NP and CNS services has been reassigned to the hospital and when the hospital bills for these services under the NP’s or CNS’s NPI number.

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Related Content

For detailed qualification and billing information for nonphysician practitioners, please refer to:

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Medicare Part B 101 Manual: Nonphysician Practitioners
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