Acute Care Advisor: Billing for NPs in acute care: Do you know the rules?
Kathy S. Magdic DNP, RN, ACNP-BC, FAANP

The Nurse Practitioner
March 2013 
Volume 38  Number 3
Pages 10 - 14
  PDF Version Available!

The Balanced Budget Act of 1997 authorized direct payment to nurse practitioners (NPs) regardless of their geographic location. Until this time, only NPs practicing in rural areas were reimbursed. This opened the door for NPs to provide care and bill for services provided to patients in any setting, including acute and critical care (CC), regardless of geographic location. With these opportunities comes the responsibility of understanding the plethora of complex rules associated with billing for services. NPs need to become familiar with each payer's unique rules. Understandably, the billing process is a challenge for NPs. Many NPs graduate from educational programs with limited (if any) knowledge of the billing process and are faced with trying to navigate the complexities of these rules, many times not knowing where to find information. To complicate matters, employers struggle with the particulars of integrating the NP role into the practice, including how to bill for NP services. The purpose of this article is to help NPs understand the rules authored by the Center for Medicare and Medicaid Services (CMS) that relate to billing in acute and CC settings; in particular, the rules related to billing Evaluation and Management (E&M) Services associated with shared visits (SVs), CC, consults, and prolonged services will be covered. CMS generates the rules for billing, but it is important to recognize that Part B Medicare Administrative Contractors, otherwise known as the regional payers, interpret the rules for their particular region, which can result in variations of how services are reimbursed from region to region.There are two components of Medicare: Medicare Part A and Medicare Part B. Medicare Part A helps cover inpatient care in hospitals including critical access hospitals and skilled nursing facilities. Medicare Part B is the medical insurance part of Medicare that covers medically necessary physician services. Whether an NP can bill for services delivered in

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