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Nonphysician Practitioners Billing for Surgical Procedures

Several providers have asked about the Medicare guidance for NPPs include billing for surgical procedures. For the purpose of this education, NPPs include NPs, PA, and CNSs.

State law or regulation governs the scope of practice in the state in which the services of a PA, NP and CNS are performed. The procedures for which NPPs can bill Medicare must also meet the requirements defined in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health Services”  (1.2 MB) sections listed below:

  1. Section 190, “Physician Assistant (PA) Services”
  2. Section 200, “Nurse Practitioner (NP) Services”
  3. Section 210, “Clinical Nurse Specialist (CNS) Services”

Minor Surgical Procedures vs. Major Surgical Procedures When Billed by an NPP

Minor surgical procedures (10-day global period) are generally covered when billed by an NPP if determined:

  • to be within the usual training of a PA/NP/CNS;
  • that the risk of performing the procedure would be acceptable when provided by a nonphysician practitioner; and
  • that the usual training includes expertise required to make the decision to perform the procedures

Major surgical procedures (90-day global period) are generally not a covered service when billed by a NPP.

Refer to the CMS Physician Fee Schedule Look Up to search for specific code related global periods.

Procedure Code Description
20240 Biopsy, bone, open; superficial (e.g., ilium, sternum, spinous process, ribs, trochanter of femur)
20615 Aspiration and injection for treatment of bone cyst
20950 Monitoring of interstitial fluid pressure (includes insertion of device, e.g., wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome
21400 Closed treatment of fracture of orbit, except "blowout"; without manipulation
21800 Closed treatment of rib fracture, uncomplicated, each
21920 Biopsy, soft tissue of back or flank; superficial
22305 Closed treatment of vertebral process fracture(s)
22310 Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing
23030 Incision and drainage, shoulder area; deep abscess or hematoma
23065 Biopsy, soft tissue of shoulder area; superficial
23500 Closed treatment of clavicular fracture without manipulation
23540 Closed treatment of acromioclavicular dislocation; without manipulation
23570 Closed treatment of scapular fracture; without manipulation
23600 Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation
23620 Closed treatment of greater tuberosity fracture without manipulation
24500 Closed treatment of humeral shaft fracture without manipulation
24560 Closed treatment of humeral epocondylar fracture, medial or lateral; without manipulation
24576 Closed treatment of humeral condylar fracture, medial or lateral; without manipulations
24650 Closed treatment of radial head or neck fracture without manipulation
24670 Closed treatment of ulnar fracture, proximal end (e.g., olecranon or coronoid process(es); without manipulation
25065 Biopsy, soft tissue of forearm and/or wrist; superficial
25500 Closed treatment of radial shaft fracture; without manipulation
25530 Closed treatment of ulnar shaft fracture; without manipulation
25560 Closed treatment of radial and ulnar shaft fractures; without manipulation
25600 Closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation
25622 Closed treatment of carpal scaphoid (navicular) fracture; without manipulation
25630 Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)); without manipulation, each bone
25650 Closed treatment of ulnar styloid fracture
26011 Drainage of finger abscess; complicated (e.g., felon)
26600 Closed treatment of metacarpal fracture, single; without manipulation, each bone
26720 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb without manipulation, each
26740 Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each
26750 Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each
27086 Removal of foreign body, pelvis or hip; subcutaneous tissue
27193 Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; without manipulation
27200 Closed treatment of coccygeal fracture
27238 Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; without manipulation
27323 Biopsy, soft tissues; superficial
27500 Closed treatment of femoral shaft fracture, without manipulation
27508 Closed treatment of femoral fracture, distal end, medial or lateral condyle, without manipulation
27516 Closed treatment of distal femoral epiphyseal separation; without manipulation
27520 Closed treatment of patellar fracture, without manipulation
27530 Closed treatment of tibial fracture, proximal (plateau); without manipulation
27560 Closed treatment of patellar fracture; without anesthesia
27750 Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation
27760 Closed treatment of medial malleolus fracture; without manipulation
27767 Closed treatment of posterior malleolus fracture; without manipulation
27780 Closed treatment of proximal fibula or shaft fracture; without manipulation
27786 Closed treatment of distal fibular fracture (lateral malleolus); without manipulation
27808 Closed treatment of bimalleolar ankle fracture (e.g., lateral and medial malleoli, or lateral and posterior malleoli or medial and posterior malleoli); without manipulation
27816 Closed treatment of trimalleolar ankle fracture; without manipulation
28400 Closed treatment of calcaneal fracture; without manipulation
28430 Closed treatment of talus fracture; without manipulation
28450 Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each
28470 Closed treatment of metatarsal fracture; without manipulation
28470 Removal of indwelling tunneled pleural catheter with cuff
28490 Closed treatment of fracture great toe, phalanx or phalanges; without manipulation
28510 Closed treatment of fracture, phalanx or plalanges, other than great toe; without manipulation each
28530 Closed treatment of sesamoid fracture
28540 Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia
28635 Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia
29355 Application of long leg cast (thigh to toes); walker or ambulatory type
29358 Application of long leg cast brace
29520 Strapping; hip
29720 Repair of spica, body cast or jacket
29740 Wedging of cast (except clubfoot casts)
29799 Application of post-op shoe
Nonphysician Practitioners Billing for Surgical Procedures
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