Part B Insider (Multispecialty) Coding Alert

Published on Sat Apr 25, 2009 PDF

The answer depends on PECOS application dates.

Question: I have a question regarding the 30-day rule for new providers. A nurse, who has successfully graduated from nurse anesthesia school and is awaiting certification, is currently allowed to provide services to Medicare members.Typically while the nurse sees patients, we practice the following sequence for credentialing: The graduate nurse sits for her certification exam; after successful exam completion, she applies for her Advanced Practice Registered Nurse (APRN) from the state; once she receives her APRN license, she obtains her national provider identifier (NPI); then she applies to Medicare. This sequence in our state could mean that the graduate has been providing services for six months before we can apply to NGS with the NPI. The new rule would indicate we can go back only 30 days from the date of the Medicare application. Does the new rule disallow new masters prepared graduate nurses from providing services to Medicare members?

Answer: Under the old rule, physician and nonphysician practitioners (NPP) could submit claims for services provided up to 27 months prior to the date of enrollment into the Medicare program.

The new rule defines the enrollment date as the later of the date an enrollment application was filed (assuming subsequent approval of the application) or the date the enrolled provider started providing services at a new location and allows billing 30 days prior to a successfully filed enrollment application.

The rule applies to new physicians and Graduate Registered Nurse Anesthetists (GRNAs). The old concern was that a provider could treat Medicare patients for more than two years (27 months) before being classified as a successful or unsuccessful Medicare provider. This dramatically shortens the time frame. It is up to the applicant or her employer to have a completed application submitted to Medicare within 30 days of the new graduate treating these patients.

Take note: CMS asserts that PECOS will improve enrollment processing to allow contractors to process applications in 30 to 45 calendar days. The current process requires 60 to 90 calendar days. Again, the important time is 30 days before an approved application was completed (the approval date could be after that period). So if taking the exam and getting her APRN license requires six months, you would only bill her services to Medicare for the final month.