Nurse visits in provider based clinics

May 27th, 2009 - Codapedia Editor
Categories:   Evaluation & Management (E/M)   Medicare  

Question:  Can you bill a nurse visit, 99211, to Medicare in a Provider Based Entity?

 Answer: You may not bill a nurse visit to Part B, for a physician service, but may bill a facility fee for a nurse visit in a PBE.

 The payment rules for a free-standing, independent physician's office and a provider based entity are different.  One of the ways they vary, is that for services in a provider based entity (PBE), the practice submits two charges: one for the professional service of the physician, which is covered under Part B, and one for the facility fee, covered under Part A.  The professional fee is charged in place of service outpatient rather than office, and so receives a slightly lower payment.  A nurse cannot bill a professional fee, only a licensed, credentialed professional can bill a professional service. 

The facility fee includes payment for the overhead expense:  facility, supplies, equipment, and staff.  A nurse may bill a facility fee for the service provided.  This is also called the technical fee.


For a patient seen in a PBE for a Coumadin check, there is no professional fee charged to Part B Medicare.  You may bill a facility fee to Part A Medicare.

The nurse visit should meet these requirements:

·      The MD must have initiated the treatment at a previous visit, and must remain involved in the patient’s care

·      The MD must be in the office when the service takes place

·      The service must be a face to face service, not a phone service. If the patient is receiving lab results over the phone, this does not constitute a nurse visit, even if the nurse saw the patient and drew the blood earlier that day.

·      The visit must be medically necessary.  Some interpret this to mean that if the Coumadin dose wasn’t changed, a nurse visit isn’t warranted.  This is one opinion.  The Medicare manuals do not address situations this specifically.  In my opinion, a nurse service is medically necessary whether the medication is changed or not.

·      The services must be clearly documented: reason for visit, patient’s symptoms or how patient is doing at home, medication dose, side effects, bleeding, etc, PTINR data, Coumadin dosage, instructions to patient.




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