Introduction
Psychiatric Clinical Nurse Specialists and Medicare Billing
A psychiatric clinical nurse specialist (CNS) might encounter patients covered by Medicare in the following ways:
A 68-year-old man visits a clinic with his wife. His wife made the appointment, and tells the CNS that her husband told her he is considering suicide.
A surgeon requests a psychiatry consultation to rule out depression in a 72-year-old man 3 days after heart surgery, because the man refuses to get out of bed.
A 45-year-old woman, permanently physically disabled following a stroke, wants to leave a nursing home and live with her daughter. The patient's internist ordered 3 sessions of psychotherapy to discuss and analyze the reality of this plan.
This article answers the following questions for psychiatric clinical nurse specialists:
How does a psychiatric CNS determine whether Medicare will reimburse for services rendered to patients?
Once a CNS has a provider number, what is the process of obtaining reimbursement?
What are the questions frequently asked by psychiatric CNSs about obtaining reimbursement from Medicare?
What are some of the problems CNSs have had in getting paid?
In the Balanced Budget Act of 1997, Congress authorized the Medicare program to reimburse CNSs when they perform physician services.
A CNS is a registered nurse who holds a graduate degree or a post-masters certificate from a program that is recognized by a national nursing accrediting body and that prepares graduates to practice as a CNS, holds national certification as a CNS in a designated specialty; and meets board of nursing requirements to practice as a clinical nurse specialist.[1] (When there is no certification examination available in a CNS' specialty area, a CNS may have met waiver requirements.) According to the National Association of Clinical Nurse Specialists, a CNS independently provides theory and research-based care to clients facilitating attainment of health goals, works with nurses to advance nursing practice to improve outcomes cost effectively, and/or provides clinical expertise to affect system-wide changes in organizations to improve programs of care.[1]
Psychiatric CNSs specialize in the diagnosis and treatment of patients with psychiatric disorders (those who have specialized mental illness and behavioral problems).[2] Data show that psychiatric CNSs provide cost-effective care with a very high level of patient satisfaction.[3,4,5,6]
Medicare is the federal health insurance program for the elderly and disabled. The Medicare program began with the Social Security Act of 1965. The United States Department of Health and Human Services, Center for Medicare and Medicaid Services (CMS) (formerly the Health Care Financing Administration) administers Medicare.
Medicare funds pay for medical services under 2 programs: Medicare Part A and Medicare Part B. Part A covers the services of hospitals, skilled nursing facilities, home health agencies, and hospices. Part B covers physician's services, medical equipment and supplies, laboratory procedures, and some home health visits. CNSs bill Medicare under Part B. Part B payments are administered by Medicare Carriers, which are local companies under contract with CMS.
Determining Eligibility for Payment
How does a psychiatric CNS determine whether he or she can get paid by Medicare for services rendered to patients?
There are 6 threshold questions that must be answered "yes" for a psychiatric CNS to determine whether he or she can get reimbursements through the Medicare program:
Does the clinician meet Medicare's qualifications for a CNS? Medicare requires that a CNS meet the following qualifications:
Hold an active license as a registered nurse, authorized to perform the services of a clinical nurse specialist, in the state where he or she practices;
Have a master's degree in a defined clinical area of nursing from an accredited educational institution; and
Hold current certification as a clinical nurse specialist from an appropriate certifying body.
Is the service to be performed one that would be a physician's service if performed by a physician? Medicare defines physicians' services as: "the professional services performed by a physician or physicians for a patient including diagnosis, therapy, surgery, consultation, and care plan oversight."[7]
To determine whether the CNS is providing physician services:
Describe the service the CNS wishes to provide.
Consult Current Procedural Terminology (CPT)[8] for the current year to determine the physician-service components of the various procedures. CPT is a manual of procedure codes published by the American Medical Association. First, read the introductory pages to the "Psychiatry" and "Evaluation and Management" sections of the manual. Then scan the entire manual to get a sense of how physicians' services are described.
Compare the service the CNS wishes to provide with the descriptions of service provided in the manual. For example, if the service to be provided is consultation, find the CPT codes for consultation, found in the "Evaluation and Management" section of the manual. The manual states that the physician-service components of consultation are history taking, examination, and medical decision-making. The manual defines medical decision-making as diagnosing and selecting management options.
Analyze whether the service the CNS provides or wishes to provide fits with the components of physician service described in the manual.
Is the service to be rendered by the CNS covered by Medicare?
Certain physician services are not covered by Medicare. For example, regular physical examinations, health maintenance screening, and counseling for well patients are physician services, but Medicare does not cover these services. For a list of noncovered services, contact the local Medicare Carrier.Is the CNS authorized to perform the service under the state law governing CNS scope of practice?
To bill Medicare for a service, the CNS must be authorized to perform that service under state law. For example, to perform a consultation, the CNS must have authority under state law to take a history, perform an examination, and diagnose and select management options. Or, state law may authorize CNSs to "perform consultations."CNSs' authority to practice varies greatly from state to state. Three examples follow.
North Carolina. The North Carolina administrative code states:
"Clinical nurse specialist practice incorporates the basic components of nursing practice as defined in Rule .0224 of this Section as well as the understanding and application of nursing principles at an advanced level in his/her area of clinical specialization which includes but is not limited to:
assessing clients' health status, synthesizing and analyzing multiple sources of data, and identifying alternative possibilities as to the nature of a healthcare problem;
diagnosing and managing clients' acute and chronic health problems within a nursing framework;
formulating strategies to promote wellness and prevent illness;
prescribing and implementing therapeutic and corrective nursing measures;
planning for situations beyond expertise, and consulting with or referring clients to other healthcare providers as appropriate;
promoting and practicing in collegial and collaborative relationships with clients, families, other healthcare professionals and individuals whose decisions influence the health of individual clients, families, and communities;
initiating, establishing, and utilizing measures to evaluate healthcare outcomes and modify nursing practice decisions;
assuming leadership for the application of research findings for the improvement of healthcare outcomes; and
integrating education, consultation, management, leadership, and research into the advanced clinical nursing specialist role."[9]
Maryland. Maryland regulations state:
"The advanced practice registered nurse psychotherapist may perform independently, autonomously and in a variety of settings, the following functions:
Establish a mental health diagnosis
Evaluate and manage psychobiological interventions
Provide individual therapy
Provide group therapy
Provide family therapy
Provide any therapy which purpose is to:
Effect change in the client in an attempt to alleviate emotional disturbances
Reverse or change maladaptive behavior and
Facilitate personality growth and development
Provide consultation to healthcare providers and others
Provide behavioral rehabilitation
Utilize advanced practice skills to independently provide (1) case management, including psychiatric rehabilitation and home care; and (2) teaching, promotion, and prevention."[10]
California. California law does not define clinical nurse specialists. In a document "Explanation of RN scope of practice and nurse practitioner practice" published on the Web site of the California Board of Registered Nursing, the following directions are given:
"Standardized procedures are the legal mechanism for RNs and NPs to perform functions which otherwise would be considered the practice of medicine. Standardized procedures guidelines are to be adhered by RNs and NPs when performing medical functions. The guidelines are described in the California Code of Regulation, Section 1474. The standardized procedures must be developed collaboratively by nursing, medicine and administration in the organized health care system where they will be utilized.
The Medical Practice Act includes diagnosis of mental or physical conditions, the use of drugs in or upon human beings and severing or penetrating tissue of human beings. As a general guide the performance of any of these functions by a RN or NP requires a standardized procedure."[11]
For the scope of practice for any state, contact the state's Board of Nursing.
Does the CNS have a physician collaborator?
Medicare requires CNSs to furnish services in collaboration with a medical doctor or doctor of osteopathy. However, the collaborating physician "does not need to be present with the CNS when the services are furnished or to make an independent evaluation of each patient who is seen by the CNS."[12]Medicare defines collaboration as "a process in which a CNS works with one or more physicians (MD/DO) to deliver health care services with medical direction and appropriate supervision as required by the law of the State in which the services are furnished. In the absence of state law governing collaboration, collaboration is to be evidenced by CNSs documenting their scope of practice and indicating the relationships that they have with physicians to deal with issues outside their scope of practice."[12]
Has the CNS applied for and received a Medicare provider number?
Providers apply using form CMS 855, available online. CNSs may not bill Medicare until they have received a provider number. Services provided while a provider number is pending must be billed as a batch after the CNS receives the provider number.
Topics in Advanced Practice Nursing eJournal. 2003;3(1) © 2003 Medscape
Cite this: Billing for Psychiatric Clinical Nurse Specialists Services Within the Medicare Program - Medscape - Feb 27, 2003.
