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MIR-2007-3AB, March 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Direct Billing and Payment for Non-Physician Practitioner (NPP) Services Furnished to Hospital Inpatients and Outpatients
Provider Types Affected
All hospitals, clinical nurse specialists (CNS), nurse practitioners (NP), and the employers of physician assistants (PA) who bill Medicare for hospital inpatient and outpatient services
Background
Section 4511(a)(2)(B) of the Balanced Budget Act of 1997 amended section 1861(b)(4) of the Social Security Act to exclude the professional services of NPs, CNSs and PAs from hospital inpatient services. Accordingly, upon the effective date of Change Request (CR) 5221, NPs and CNSs 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.
Key Points
This article and Change Request (CR) 5221 describe the removal of the paragraph in the Medicare Claims Processing Manual, Chapter 12 Section 120.1 that contains outdated policy on payment for NP and CNS services furnished in a hospital setting. The changes are as follows:
- 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 Medicare billing number or their National Provider Identifier (NPI), once the NPI is effective.
- 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 Medicare billing number or the PA’s NPI, once the NPI is effective.
- 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 Universal Provider Identifier Number (UPIN).
- Your Medicare carrier will identify and reprocess any claims submitted by NPs, CNSs, or the employer of a PA that have been denied since January 1, 2006, because the claim listed a hospital inpatient or outpatient setting place of service.
- For claims for dates of service prior to January 1, 2006, the carrier will reopen claims that were denied because they listed a hospital inpatient or outpatient place of service. However, the carrier will only reopen these claims if the NP, CNS, or employer of the PA brings the claim to the attention of the carrier and the carrier will pay these claims for dates of services on or after the January 1, 1998, effective date retroactive to the actual date that the services were rendered.
Additional Information
The official instructions, CR5221, issued to your Medicare carrier regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R1168CP.pdf  on the CMS Web site. A revised Chapter 12, Section 120.1, Direct Billing and Payment, of the Medicare Claims Processing Manual is attached to CR 5221.
If you have questions, please contact your Medicare carrier at their toll-free number which may be found on the CMS Web site at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip. 
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5221
Pub. 100-4, Transmittal# R1168CP, CR# 5221
Related CR Release Date: January 26, 2007
Effective Date: April 26, 2007
Implementation Date: April 26, 2007
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