Maximize Your Reimbursement for Services Provided by CNMs and NPs
Published on Wed Jul 01, 1998
In order to augment their services and improve efficiency, many ob/gyn practices are increasing their use of certified nurse midwives (CNMs) and nurse practitioners (NPs). The American College of Nurse-Midwives confirms this trend by reporting a 300 percent growth in the number of CNMs in the last decade. In eight years, the number of annual deliveries performed by CNMs has more than doubled. No wonder ob/gyn practices are increasingly concerned about coding for these providers. In fact, Karen S. Fennell, RN, MS, senior policy analyst for the American College of Nurse-Midwives, says, One of the most commonly asked questions by CNMs is, Which prenatal codes do I bill under?
1. Coding For A Mid-Level Provider
The trick to coding for mid-levels has nothing to do with the fact that the provider is not a physician, says Trudy A. Brody, billing office supervisor for an ob/gyn practice with five mid-level providers in Medford, OR. You use the exact same codes as you would use for the physician. The difference comes in how the claim is reimbursed, and reimbursement depends on how the service by the CNM or NP is provided. If the service is incident to the physicians professional services, then reimbursement should be at the same level as the physician. On the other hand, if the CNM or NP is providing a professional service independent of the physician, then reimbursement is lowertypically only 65 to 85 percent of what the physician might collect for the same service.
Note: The Balanced Budget Amendment of 1997 increased Medicare reimbursement for physician assistants and NPs to 85 percent of the physician fee schedule and allowed them to bill under their own provider identification numbers. However, carriers were given until July 1, 1998 to implement the new policy. Check with your local Medicare carrier about submitting claims.
2. Incident To Services and Medicare Rules
With incident to services getting reimbursed at 100 percent of physician rates, the logical question to ask is why not code all services that way? The good news is that NPs and CNMs who work for ob/gyn practices are providing their services incident to the physician most of the time. Incident to means that the mid-level provider is acting on behalf of the physician. It is as if the ob/gyn herself performed the service and, therefore, the practice is reimbursed as such.
But, when billing Medicare, a coder cannot assume that the mid-level provider is performing services incident to the physician. Both the mid-level and the physician must meet certain qualifications set by Medicare in order to be eligible.
In fact, according to Neil B. Caesar, JD, president of The Health Law Center in Greenville, SC, practices using mid-levels can be exposed [...]
