Rumor control: The rumor-of-the month is "NPs can't bill for visits above 99213"

Yes, NPs can bill for 99214 and 99215 visits with the following caution: Beware in states where the scope of NP practice is not specifically defined to include comprehensive evaluations.

The source of the rumor-of-the-month is an attorney based in Philadelphia who is going around the country speaking on Medicare fraud and abuse, and giving out the advice that NPs should not bill visits above level 99213 or 99303; that is, no 99214 or 99214 for established patients, and no 99204 or 99205 for new patients. She bases her opinion on the theory that the scope of practice of NPs does not include comprehensive evaluations.

This attorney cites no particular law when she gives her opinion. And when pressed to cite a law, rule, or regulation supporting her opinion, she says she cannot, but that she believes HCFA agrees with her. A letter is on its way to HCFA to ask to confirm or deny her belief.

The problem is that she is a well-known expert on Medicare fraud and abuse and other attorneys listen to her. And other attorney's clients listen to them, so there are practices and independent practice associations around the country which are putting out policies that NPs cannot see patients at visits higher than 99213.

NPs confronted with a local policy which restricts them from billing the higher level evaluation and management codes should respond that the advice this attorney is giving has no sound basis in law. No NP or employer of an NP has been cited for fraud or abuse for appropriately billing 99214 or 99215.

HCFA's comment to date on the issue of what codes an NP can bill is as follows:

"Nurse practitioners and clinical nurse specialists have been educated and specifically trained to furnish primary care and certain other services that have traditionally been furnished by physicians. As long as the services that nonphysician practitioners furnish are medically reasonable and necessary, meet Medicare requirements, and fall within the scope of services that they are licensed to perform, then Medicare program covers the services." Final rule on "Medicare Program; Revisions to Payment Policies...", Federal Register, November 2, 1998.

NPs should continue to bill 99214 and 99215 visits, if the services performed and documented supports that level of coding.

This tip is excerpted from a recent issue of The Green Sheet, a newsletter on compensation and reimbursement for nurse practitioners, published monthly by the Law Office of Carolyn Buppert.

Subscriptions: $25 per year (12 issues), mailed first class. To receive The Green Sheet every month, mail your name, address and a check for $25 to Law Offices of Carolyn Buppert, 1419 Forest Drive, Suite 205, Annapolis, MD 21403.

Updated June 14, 1999


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