Effective for services rendered after January 1, 1998, any individual who is participating under the Medicare program as a clinical nurse specialist (CNS) for the first time ever, may have his or her professional services covered if he or she meets the qualifications listed below and he or she is legally authorized to furnish CNS services in the State where the services are performed. CNSs who were issued billing provider numbers prior to January 1, 1998, may continue to furnish services under the CNS benefit.
Payment for CNS services is effective on the date of service, that is, on or after January 1, 1998, and payment is made on an assignment-related basis only.
A. Qualifications for CNSs
In order to furnish covered CNS services, a CNS must meet the conditions as follows:
1. Be a registered nurse who is currently licensed to practice in the State where he or she practices and be authorized to furnish the services of a clinical nurse specialist in accordance with State law;
2. Have a master’s degree in a defined clinical area of nursing from an accredited educational institution; and
3. Be certified as a clinical nurse specialist by a recognized national certifying body that has established standards for CNSs.
The following organizations are recognized national certifying bodies for CNSs at the advanced practice level:
• American Academy of Nurse Practitioners;
• American Nurses Credentialing Center;
• National Certification Corporation for Obstetric, Gynecologic and Neonatal Nursing Specialties;
• Pediatric Nursing Certification Board (previously named the National Certification Board of Pediatric Nurse Practitioners and Nurses);
• Oncology Nurses Certification Corporation;
• AACN Certification Corporation; and
• National Board on Certification of Hospice and Palliative Nurses.
B. Covered Services
Coverage is limited to the services a CNS is legally authorized to perform in accordance with State law (or State regulatory mechanism provided by State law).
The services of a CNS may be covered under Part B if all of the following conditions are met:
• They are the types of services that are considered as physician’s services if furnished by an MD/DO;
• They are furnished by a person who meets the CNS qualifications (see subsection A);
• The CNS is legally authorized to furnish the services in the State in which they are performed;
• They are furnished in collaboration with an MD/DO as required by State law (see subsection C); and
• They are not otherwise excluded from coverage because of one of the statutory exclusions. (See subsection C.)
2. Types of CNS Services that May be Covered
State law or regulations governing a CNS’ scope of practice in the State in which the services are furnished applies. Carriers must develop a list of covered services based on the State scope of practice.
Examples of the types of services that a CNS may furnish include services that traditionally have been reserved for physicians, such as physical examinations, minor surgery, setting casts for simple fractures, interpreting x-rays, and other activities that involve an independent evaluation or treatment of the patient’s condition. Also, if authorized under the scope of his or her State license, a CNS may furnish services billed under all levels of evaluation and management codes and diagnostic tests if furnished in collaboration with a physician.