- Introduction
- About Provider Outreach and Education
- ABN for Not Reasonable and Necessary Denials
- Appeals/Reopenings
- Assignment of Benefits
- Comprehensive Error Rate Testing
- CMS-1500 Claim Form
- Deceased Beneficiary Claims
- Electronic Data Interchange
- Evaluation and Management Services
- Fraud and Abuse
- Health Professional Shortage Area
- Hospice
- Limiting Charge
- Medical Policy Development
- Medigap
- Modifiers
- Nonphysician Practitioners
- National Provider Identifier
- Participation Program
- Payment Floor Standards
- Provider Enrollment
- Refunds and Overpayments
- Ordering and Referring Claims Information
- Return/Reject
- Standard Remittance ANSI Codes and Remittance Advice
- Appendix 1: Forms
- Appendix 2: Glossary
- Appendix 3: Place of Service Codes
Medicare Part B 101 Manual
Nonphysician Practitioners
Table of Contents
- Nonphysician Practitioners
- Direct Billing/Payment for NPP Services Furnished to Inpatients and Outpatients
- Related Content
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.
- Medicare reimburses nonphysician practitioners at a rate of 85% of the physician fee, as stated in Medicare’s physician fee schedule.
- 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 their own PTAN and submit claims to Medicare under this/her NPI under certain conditions.
- Provisions of the Medicare Program will override state licensure.
Direct Billing/Payment for NPP Services Furnished to Inpatients and Outpatients
NPs, CNS and PAs 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.
Related Content
For detailed qualification and billing information for nonphysician practitioners, please refer to:
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60.2
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 180–210
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Sections 30.6–30.6.10, 110–140
Reviewed 9/29/2023