Understanding the Nuances of Medicare Billing for Nurses

• Through accurate documentation and coding, nurses play a crucial role in medicare billing.
• By understanding the nuances of billing codes, nurses can help patients know what reimbursement options are available.
• Learn the current updates to the CPT Coding System and how this affected payments for different types of services.

Nurses must accurately document and bill their services in the complex healthcare billing world. Nurses must understand Medicare billing to navigate its complexities since millions of Americans rely on it. This article covers Medicare billing for nurses’ basics, considerations, updates, challenges, and best practices. 

Medicare billing is crucial to healthcare reimbursement, and nurses are essential. Nurses help Medicare bill healthcare services accurately by documenting patient care and coding. Nurses must understand Medicare billing to maximize reimbursement and comply with regulations.

How Does Medicare Billing and Reimbursement Work? 

CMS determines Medicare reimbursement rates for all medical services and equipment. The assignment requires providers to accept Medicare fees. 

Patients cannot be charged for the difference between Medicare and their usual rates. Part A and Part B providers receive most Medicare payments. 

You must still pay your plan’s copayments, coinsurance, and deductibles. 

Medicare Part A 

Medicare Part A covers hospitals, hospice, limited home healthcare, and skilled nursing. 

If your provider accepts Medicare assignment, Medicare covers all Part A expenses. You pay for all your co-payments, deductibles, and coinsurance. 

If a facility fails to file a claim or a provider bills you because they don’t participate in Medicare, you may need to file a claim. 

You can check all covered expense claims in two ways: 

• Medicare summary notices are mailed every three months 

• Log in to MyMedicare.gov to check the claims status 

Medicare Part B 

Patient visits to the doctor, outpatient care, and preventive services are all covered by Medicare Part B. 

Medicare Advantage (Part C) 

Since it is private insurance, Medicare Advantage or Part C operates in a different manner. In addition to coverage under Part A and Part B, you may also be eligible for additional coverage, which may include dental, vision, prescription drug, and other plans. 

Medicare Part D 

Plan coverage for Medicare Part D, also known as coverage for prescription drugs, is provided by private insurance companies. What medications are covered by each plan is determined by a different set of rules. 

Incorporating Nursing Complexity in Reimbursement Coding Systems

The complexity of nursing

Richards and Borglin defined nursing as the quintessential ‘complex intervention—defined as an activity that contains a number of component parts with the potential for interactions between them that, when applied to the intended target population, produce In a complex system like the healthcare system, a nurse performs a complex intervention every time she cares for a patient or teaches another nurse. 

Implications of missed care

Lack of resources due to the global health cost crisis, complexity compression, and hospital administrators’ lack of nursing complexity knowledge can lead to high missed care rates. 

Missed care increases healthcare costs due to longer stays and repeated readmissions to manage complications and adverse outcomes, which could have been avoided if nurses had fully provided care. 

Nuances of Medicare Billing for Nurses

What is the method for calculating Medicare reimbursement for nurse practitioners? 

Medicare pays doctors a set amount. Medicare pays nurse practitioners 85% of physician rates. So, if a doctor treats a patient, Medicare reimburses $100, and the NP would be reimbursed $85 (a technicality can help your practice avoid lower reimbursement rates). 

Medicare Documentation Guidelines for Reimbursements 

Medicare made $5.8 billion in improper payments for skilled nursing facility (SNF) services in one year. Clinical records are used to make payment decisions, so they must accurately reflect the patient’s condition and treatments. 

SNF documentation is complicated and requires reading Medicare guidelines. CMS requires skilled nursing facilities to keep clinical records on each resident in accordance with professional standards and practices: 

1. Complete 

1. Correctly documented 

1. Easily accessible 

1. Organized methodically 

Note that this guidance allows the facility to use paper charting or an EHR system. When reviewing documentation requirements, your facility should consider state regulations that may be stricter than federal ones. EHRs require data control and security systems. Staff should only access and enter documentation if qualified. 

Updates to the CPT Coding System and Medicare Payment 

Start the new year by learning about 2023 CPT coding, Medicare payment policies, and Medicare’s Quality Payment Program changes. Hospital and nursing home evaluation and management (E/M) services and prolonged service reporting have undergone major coding changes.  

E/M CODING

Hospital and nursing home visits. This year’s biggest E/M coding changes are in hospitals and nursing homes, which now use the same code-level selection criteria as office/outpatient services. Physicians will choose codes for these services based on their patient care time or medical decision-making. 

Hospital and nursing home E/M codes will use the same MDM table CPT as office-based codes, with a few CPT revisions: 

• The low-level MDM elements for the problems category have been updated to include “1 stable acute illness” and “1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care.” 
• Additional decisions on “escalation of hospital-level of care” and “parenteral controlled substances” for high-risk MDM elements 
• Only initial nursing facility visits have “multiple morbidities requiring intensive management” in the risk category. 

Reporting these services is also affected by other CPT changes. CPT has done this for now:

• A single-family of hospital inpatient and observation codes 99221-99223 and 99231-99233 
• Redefined the lowest level of emergency department codes (99281) to describe visits without a doctor or other qualified health care professional (like office-visit code 99211), 
• A separate code for nursing home annual exams was removed and replaced with subsequent nursing home visits (99307-99310). 
• Combined “Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services” into “Home or Residence Services.” 

Multiple E/M Services on the Same Day

The CPT guidelines for hospital E/M now allow the reporting of multiple services when a patient is admitted to inpatient or observation status during a visit to an office or emergency department. Clinicians should add modifier 25 to the initial service and report the hospital-based service (no modifier required).  

In these cases, the Centers for Medicare & Medicaid Services (CMS) will continue to require clinicians to report only one hospital visit per calendar date. Whether non-Medicare payers follow CPT or Medicare’s guidance is unknown. 

Prolonged services

In the office (99354-99355) and inpatient (99356-99357) settings, CPT has removed codes for prolonged E/M services with direct patient contact. Since the 2021 changes, physicians can report prolonged office services using code 99417 (with 99205 or 99215). That will be the only option. For long-term hospital and nursing home services, 99418 will be used. 

Once they exceed the minimum time of the highest level of service by 15 minutes, CPT allows clinicians to report 99417 and 99418 with a primary E/M code for each setting. Another difference between CPT and Medicare. Before reporting prolonged service codes, Medicare requires clinicians to exceed the highest E/M level by 15 minutes.  

CMS has developed HCPCS codes to report prolonged services to Medicare under those conditions: 

• G2212, extended office or outpatient services, 
• G0316, extended inpatient and observation care, 
• G0317, Extended nursing facility services 
• G0318, extended home/residence services. 

Two of CPT’s previous prolonged services codes, 99358 and 99359, are still used for non-face-to-face services on a different date. Instead of “Prolonged evaluation and management service before and/or after direct patient care,” those codes now read “Prolonged service on date other than the face-to-face evaluation and management service without direct patient contact.” 

Medicare Payment Policy Changes 

CMS planned to set the 2023 conversion factor at $33.06, 4.5% lower than 2022. The expiration of Congress’ 3% conversion factor increases in 2022 caused most of that reduction.  

CMS’s budget neutrality adjustments to offset regulatory changes that increase RVUs for hospital, nursing facility, and home E/M services accounted for the remaining 1.5% reduction. However, Congress reduced the cut, and President Biden signed a budget bill with a 2% reduction before the new year. 

The Bottom Line

In conclusion, nurses help navigate Medicare billing and reimbursement by ensuring accurate documentation and coding to maximize reimbursement and comply with regulations. Medicare’s 2023 CPT coding revisions and payment adjustments demonstrate the dynamic nature of healthcare billing, requiring nurses to stay informed to avoid improper payments. 

Recognizing nursing intervention complexity and addressing missed care rates through resource allocation and nursing complexity knowledge improve patient outcomes and the healthcare system’s financial integrity. Thus, nurses must continue to learn Medicare billing, adopt best documentation practices, and monitor changing regulatory landscapes to ensure quality care delivery.

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