Medicare Billing for Certified Nurse-Midwifery Services
Published on Sat May 01, 1999
Editors Note: Many ob/gyn practices are extending their services through the use of certified nurse midwives (CNM) who provide care for ob patients. CNMs are also providing Medicare-reimbursable services to elderly and disabled gyn patients. OCA asked Senior Policy Analyst for the American College of Nurse Midwives, Karen S. Fennel, RN, MS, to explain CNM reimbursement.
The laws and regulations governing billing for nurse-midwifery services under federal programs such as Medicare are separate and different from billing for nurse practitioners and physician assistants services.
In 1987, a federal law was passed that provided for coverage of nurse-midwifery services under the Medicare program. Payments for covered services were to be made on the basis of a fee schedule established by the Secretary of Health and Human Services. The effective date for coverage was July 1, 1988. At that time, coverage of paid services was limited to the maternity cycle. The law provided the Secretary with little guidance as to how the fee schedule should be established, except to stipulate that payment for the nurse-midwife services cannot be greater than 65 percent of the applicable prevailing charge for the same service when performed by a physician. The law further specified that payments must be made on an assignment-only basis. This means that both coinsurance by the beneficiary and the Medicare deductibles are applicable to payment for the CNM services and the CNM may not charge additional fees. In 1993, the law was amended to include payment of all covered services that a CNM is legally authorized to perform under state law.
Definitions
Under Medicare, a Certified Nurse-Midwife (CNM) is defined as a registered nurse who has successfully completed a program of study and clinical experience meeting guidelines prescribed by the Secretary, or who has been certified by an organization recognized by the Secretary. 42 U.S.C. 1395x (gg)(2).
Certified Nurse-Midwife (CNM) services are such services furnished by a CNM, as defined above, and such services and supplies furnished as an incident to CNM services which the CNM is legally authorized to perform under State law (or as would otherwise be covered if furnished by a physician or as an incident to a physicians services). 42 U.S.C. 1395x(gg)(1).
Billing Under Medicare
When billing for Medicare services, the Health Care Financing Administration (HCFA) 1500 form should be used. The form requests that the provider use his or her unique provider identification number (UPIN). The form also requires that the provider identify who performed the services. Billing can be performed by a corporate entity or employer. This means the check for the payment of the service will be paid out to that entity. The midwife must have a legal relationship with that group. For example, the CNM can be part [...]
