Medicare rules - Nurse Practitioner (NP) Services

Effective for services rendered after January 1, 1998, any individual who is participating under the Medicare program as a nurse practitioner (NP) for the first time ever, may have his or her professional services covered if he or she meets the qualifications listed below, and he or she is legally authorized to furnish NP services in the State where the services are performed. NPs who were issued billing provider numbers prior to January 1, 1998, may continue to furnish services under the NP benefit.

Payment for NP services is effective on the date of service, that is, on or after January 1, 1998, and payment is made on an assignment-related basis only.


A. Qualifications for NPs

In order to furnish covered NP services, an NP must meet the conditions as follows:

• Be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner in accordance with State law; and be certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners; or
• Be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner by December 31, 2000.
The following organizations are recognized national certifying bodies for NPs at the advanced practice level:


• American Academy of Nurse Practitioners;
• American Nurses Credentialing Center;
• National Certification Corporation for Obstetric, Gynecologic and Neonatal Nursing Specialties;
• Pediatric Nursing Certification Board (previously named the National Certification Board of Pediatric Nurse Practitioners and Nurses);
• Oncology Nurses Certification Corporation;
• AACN Certification Corporation; and
• National Board on Certification of Hospice and Palliative Nurses.

The NPs applying for a Medicare billing number for the first time on or after January 1, 2001, must meet the requirements as follows:

• Be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner in accordance with State law; and
• Be certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners.


The NPs applying for a Medicare billing number for the first time on or after January 1, 2003, must meet the requirements as follows:
• Be a registered professional nurse who is authorized by the State in which the services are furnished to practice as a nurse practitioner in accordance with State law;
• Be certified as a nurse practitioner by a recognized national certifying body that has established standards for nurse practitioners; and
• Possess a master’s degree in nursing.


B. Covered Services
Coverage is limited to the services an NP is legally authorized to perform in accordance with State law (or State regulatory mechanism established by State law).



1. General
The services of an NP may be covered under Part B if all of the following conditions are met:
• They are the type that are considered physician’s services if furnished by a doctor of medicine or osteopathy (MD/DO);
• They are performed by a person who meets the definition of an NP (see subsection A);
• The NP is legally authorized to perform the services in the State in which they are performed;
• They are performed in collaboration with an MD/DO (see subsection D); and
• They are not otherwise precluded from coverage because of one of the statutory exclusions.


1. Types of NP Services That May Be Covered
State law or regulation governing an NP’s scope of practice in the State in which the services are performed applies. Consider developing a list of covered services based on the State scope of practice. Examples of the types of services that NP’s may furnish include services that traditionally have been reserved to physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting x-rays, and other activities that involve an independent evaluation or treatment of the patient’s condition. Also, if authorized under the scope of their State license, NPs may furnish services billed under all levels of evaluation and management codes and diagnostic tests if furnished in collaboration with a physician.


2. Services Otherwise Excluded From Coverage
The NP services may not be covered if they are otherwise excluded from coverage even though an NP may be authorized by State law to perform them. For example, the Medicare law excludes from coverage routine foot care, routine physical checkups, and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Therefore, these services are precluded from coverage even though they may be within an NP’s scope of practice under State law.