AAHPM — Summer Quarterly 2012
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Gail Austin Cooney

Q & A on Nurse Practitioners

We often receive questions about nurse practitioner billing in hospice and palliative care. Below are answers to some commonly asked questions.

Q. When can a nurse practitioner (NP) bill Medicare for services to a hospice patient?

A. When state law permits, an NP may act as a hospice patient’s attending physician. In this role only, an NP may bill for physician-level services. If the NP is not employed by the hospice, he or she should bill Medicare Part B using the GV modifier; the NP will be paid at 85% of the Medicare allowable fee. If the NP is employed by or under contract with the hospice, he or she should bill the hospice.

Q. May an NP bill when he or she makes a face-to- face recertification visit but finds the patient symptomatic and makes changes in the medications?

A. No. Unless the NP is the patient’s hospice attending physician, he or she cannot bill for direct patient care services to a hospice patient. Face-to- face visits are considered an administrative responsibility related to recertification. The hospice may choose to reimburse the NP, but this comes out of the daily Medicare payment and is not separately billed.

Q. Can an NP bill for “consulting” physician services with a Medicare hospice patient?

A. No. Only when an NP is the patient’s attending physician may physician-level services be billed to Medicare by the hospice.

Q. If a physician is contracted to provide physician services to hospice patients, can the physician delegate visits to his or her employed NP?

A. No. Hospice can only bill for NP services if the NP is the hospice patient’s attending physician (42 CFR 418.56b). Even if the physician sees the patient on the same day, only those services performed personally by the physician may be billed.

Q. How does the Centers for Medicare & Medicaid Services (CMS) define hospice attending physician?

A. CMS defines an attending physician for a hospice patient as the physician chosen by the patient who is most involved in the management of the patient’s terminal diagnosis. This individual does not have to be their primary care physician. There is a strong emphasis on patient choice. If the patient does not have an independent attending physician and the hospice employs both a medical director and an NP, the patient must be given a choice between a physician or an NP to act as his or her attending physician for hospice care.