Payment for Professional Services of Certain Nonphysician Practitioners
and Incidental Services and Supplies Furnished Incident
to their Professional Services
Current Status as of October 1, 1999
These provisions became effective January 1, 1998, along
with other provisions of the BBA 97. A final rule, published
November 2, 1998 (63
Federal Register, text and PDF, 58814-59190), provided
regulatory language for these BBA provisions.
Background/Summary
The final rule implements BBA provisions, effective January
1, 1998, for payment of the services of nonphysician providers
defined as, nurse practitioners, clinical nurse specialists,
certified nurse-midwives, and physician assistants.
General payment rule for services of nonphysician providers.
For these nonphysician providers, BBA authorizes the Medicare
program to pay directly for professional services and incidental
services and supplies furnished in any delivery setting (except
rural health clinics and Federally qualified health centers),
regardless of whether the settings are located in rural and
urban areas, but only if the facility or other providers of
services do not charge or are not paid any amounts with respect
to the furnishing of the same service. (A hospital or clinic
may continue to bill a technical or facility fee but not a
professional fee for the same service.) The rule specifies
which services and supplies (including drugs and biologicals)
furnished incident to a nonphysician practitioner's professional
services that will be covered by Medicare in sections 410.74,
410.75, 410.76, and 410.77 of the rule.
Alternatively, physicians may continue to bill for the services
furnished by these nonphysician practitioners "incident
to" a physician's professional services. The rule specifies
the billing requirements for services furnished by physician
assistants independently and "incident to" the services
of a physician. The rule reiterates Medicare's "incident
to" billing policy for those services performed by a
nonphysician provider under the direct supervision of a physician
and billed by that physician in his/her name.
Payment for nurse practitioners and clinical nurse specialist
services.
Section 410.75 and section 410.76 sets out the qualifications
and conditions for payment of nurse practitioners' and clinical
nurse specialist services respectively. The general payment
rule above applies. Effective January 1, 1998, for all services,
85 percent of the physician fee schedule amount is paid.
Section 410.150 authorizes payment for services when furnished
in collaboration with a physician in all settings. For the
purposes of Medicare coverage, nurse practitioners and clinical
nurse specialists must meet the standards for a collaborative
process, as established by the State in which they are practicing.
In the absence of State law governing collaborative arrangements,
collaboration is a process in which these nonphysician practitioners
have a relationship with one or more physicians to deliver
health care services. Such collaboration is evidenced by nurse
practitioners or clinical nurse specialists in documenting
their scope of practice and indicating the relationship that
they have with physicians to deal with issues outside the
scope of their practice. The collaborating physician does
not need to be present when services are furnished or to make
an independent evaluation of each patient who is seen by the
nurse practitioner or clinical nurse specialist.
Section 410.76 sets forth the new qualifications for clinical
nurse specialists. A clinical nurse specialist must be: a
registered nurse with a state license; have a master's degree
in a defined clinical area of nursing; and be certified as
a clinical nurse specialist by the American Nurse Credentialing
Center.
Payment for physician assistants' services.
Section 410.74 of the rule sets out the qualifications and
conditions for payment of services provided by physician assistants.
Section 414.52 states that for services furnished by physician
assistants, 85 percent of the physician fee schedule amount
will be paid. For assistant-at-surgery services, 85 percent
of the physician fee schedule amount that would be allowed
if the assistant-at-surgery were furnished by a physician,
will be paid. (This same payment rule applies to nurse practitioners
and clinical nurse specialists acting as assistants-at-surgery.)
Payment for nurse mid-wives' services.
Section 410.77 of the rule sets out the qualifications and
conditions for payment for nurse mid-wives.
Administration Action
Final regulations were published November 2, 1998 (63
Federal Register, text and PDF, 58814-59190).
Contacts
Denise Dodero, Associate Vice President
AAMC Health Care Affairs
ddodero@aamc.org
(202) 828-0493
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