Ober|Kaler Elicits Correction to CMS Medlearn Matters #SE0418

Medicare Skilled Nursing Facilities
Employing Non-physician Practitioners
May Bill Part B for Their Professional Services
Rendered During a Part A Stay

Ober|Kaler is pleased to report a successful outcome to discussions between our firm, acting on behalf of a national coalition of the National Conference of Gerontological Nurse Practitioners, the American Academy of Nurse Practitioners, the American College of Nurse Practitioners and the American Nurses Association (the NP Coalition), and the Centers for Medicare and Medicaid Services (CMS) regarding the services of nurse practitioners and other non-physician practitioners (NPPs) employed by Medicare certified skilled nursing facilities (SNFs).

The issue arose with CMS's Medlearn Matters article #SE0418, issued July 2, 2004, in which CMS advised that when a SNF-employed NPP renders a professional service to a resident otherwise receiving skilled care covered under Part A, that professional service is bundled in the SNF's Part A rate. This was CMS's stated policy notwithstanding that the same professional service would be billable under Part B if rendered by an NPP not employed by the SNF.

After researching the available information identifying how NPP services were furnished and billed historically to the Medicare program, up to and including the 1995 base year used to establish the SNF prospective payment system, we approached CMS officials to discuss the issue. CMS showed a gratifying willingness to engage in substantive discussions with us and to review our submissions.

In response to our inquiry, CMS confirmed that our understanding was correct. Specifically, Medicare SNFs may employ NPPs in a manner permitted by state law. When an NPP renders a service that is covered under Part B, the employing SNF may submit the claim to Part B during the resident's Part A stay. Under separate rules, however, the employed NPP is not permitted to certify skilled status for Part A benefits.

Not only is this outcome correct, but the resulting clarification removes a significant barrier to SNFs that wish to make NPP services available in their facilities, particularly in communities where it may be impractical for the NPP to establish or join a private practice.

This change will become official when the Medlearn Matters correction is posted.

In a separate issue arising from Medlearn Matters article #SE0418, Ober|Kaler has approached CMS seeking a change to that article's statements pertaining to countersignature requirements. On behalf of the NP Coalition, we have urged CMS officials to correct article #SE0418 to clarify that, based on the federal Requirements of Participation for Long Term Care Facilities, when an NPP employed by a facility performs a visit that need not be "personally performed" by the attending physician, state law governs whether physician countersignature is required. That corollary request remains pending.

A copy of CMS's written response to our NPP billing inquiry
is available for download at
www.ober.com/shared_resources/news/
newsletters/pdf/hl_cmsresponse.pdf.

If you have any questions concerning this outcome, please contact
Howard L. Sollins at 410-347-7369 or hlsollins@ober.com.