Nurse Practitioners as Attending Physicians

40.1.3.2 - Nurse Practitioners as Attending Physicians (Rev. 246, Issued: 09-14-18, Effective: 12-17- 18, Implementation: 12-17-18) A nurse practitioner is defined as a registered nurse who is permitted to perform such services as legally authorized to perform (in the state in which the services are performed) in accordance with State law (or State regulatory mechanism provided by State law) and who meets training, education and experience requirements described in 42 CFR 410.75. If a beneficiary does not have an attending physician or a nurse practitioner who has provided primary care prior to or at the time of the terminal illness, the beneficiary may choose to be served by either a physician or a nurse practitioner who is employed by the hospice. The beneficiary must be provided with a choice of a physician or a nurse practitioner. Medicare pays for attending physician services provided by nurse practitioners to Medicare beneficiaries who have elected the hospice benefit and who have selected a nurse practitioner as their attending physician. This applies to nurse practitioners without regard to whether they are hospice employees. Physician services provided by nurse practitioners may be billed to Medicare only if the: • Nurse practitioner is the beneficiary's designated attending physician; and • Services are medically reasonable and necessary; and • Services are performed by a physician in the absence of the nurse practitioner; and • Services are not related to the certification of terminal illness. If the nurse practitioner is employed by the hospice, the hospice can bill Part A for physician services meeting the above criteria on a hospice claim. If the nurse practitioner is not employed by the hospice, the nurse practitioner can bill Part B for physician services meeting the above criteria. Payment for nurse practitioner services is made at 85 percent of the physician fee schedule amount. Services that are duplicative of what the hospice nurse would provide are not separately billable. Nurse practitioners cannot certify or re-certify an individual as terminally ill, meaning that the individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course. In the event that a beneficiary’s attending physician is a nurse practitioner or a physician assistant, the hospice medical director or the physician member of the hospice IDG certifies the individual as terminally ill. Hospice nurse practitioners may conduct face-to-face encounters as described in §20.1(5) as part of the certification process, but are still prohibited by statute from certifying the terminal illness.