Nonphysician Practitioners Billing for Surgical Procedures

Several providers have asked about the Medicare guidance for NPPs include billing for surgical procedures. For the purpose of this education, NPPs include NPs, PA, and CNSs.

State law or regulation governs the scope of practice in the state in which the services of a PA, NP and CNS are performed. The procedures for which NPPs can bill Medicare must also meet the requirements defined in the CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, “Covered Medical and Other Health Services” sections listed below:

1. Section 190, “Physician Assistant (PA) Services”
2. Section 200, “Nurse Practitioner (NP) Services”
3. Section 210, “Clinical Nurse Specialist (CNS) Services”

Minor Surgical Procedures vs. Major Surgical Procedures When Billed by an NPP

Minor surgical procedures (10-day global period) are generally covered when billed by an NPP if determined:

• to be within the usual training of a PA/NP/CNS;
• that the risk of performing the procedure would be acceptable when provided by a nonphysician practitioner; and
• that the usual training includes expertise required to make the decision to perform the procedures

Major surgical procedures (90-day global period) are generally not a covered service when billed by a NPP.

Refer to the CMS Physician Fee Schedule Look Up to search for specific code related global periods.

Below are exceptions to this rule that have been determined by our Medical Policy team. These major surgery procedures may be billed by nonphysician practitioners.

Reviewed 8/28/2024