Medicare Compliance & Reimbursement

Manual misprint leads to missed reimbursement for NPs.

If you're seeing denials for nurse practitioners (NPs) in the hospital, you should raise your concerns with the Centers for Medicare & Medicaid Services (CMS).

The problem: Some carriers in the Southwest, and possibly elsewhere, are denying claims for NPs in the hospital, says consultant Quinten Buechner with ProActive Consulting in Cumberland, WI. The carriers may also be bundling hospital claims for other non-physician practitioners (NPPs) such as physician assistants, he says.

This problem doesn't apply to shared visits, where an NPP bills under the physician's number for part of a hospital visit, Buechner adds.

Appeals: Northwest Louisiana Nephrology (NLN) in Shreveport appealed when its local carrier denied several claims for an NP's services in the hospital. The carrier cited language in the Medicare Carrier Manual (MCM) Section 120.1, which says the hospital should be financially responsible for any NP's services.

This MCM section doesn't take into account situations where the NP works for the doctor's office, not the hospital, notes coder Wanda Carter with NLN. But when she pointed this out, the carrier still wanted NLN to send in the claims for review.

The carrier claimed that CMS had sent a directive saying the carrier was processing NP claims incorrectly, Carter adds.

CMS steps in: In the end, NLN called the local CMS regional office and explained the situation. NLN provided examples of the patients and the denial codes. The regional office called back in two days, after talking to the carrier. The regional office had given the carrier one week to come up with a plan to correct the denials and pay the claims it had already denied, Carter reports. So far, NLN has received one claim payment.

Typo: The language in the MCM saying you can't bill for an NP in the hospital is a "clerical error," says William Rogers, head of the Physician Regulatory Issues Team (PRIT) at CMS. This is "obviously incorrect." The PRIT has had this problem on its radar since February, and has been working to change the manual.

"Obviously a NPP providing independent clinical services, not nursing care, can be reimbursed separately the same as anyone else," Rogers says.

Rogers says he hasn't been aware of any denials resulting from this mistake in the manual. CMS has been so busy with other issues the correction hasn't come out yet.

Bottom line: If your carrier is denying NP hospital claims, you should contact your local CMS regional office or the PRIT. The PRIT is online at www.cms.hhs.gov/prit/.