CMS Pub. 100-02, ch. 15, § 210

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 or a doctor of nursing practice (DNP) doctoral degree; 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;

• National Board on Certification of Hospice and Palliative Nurses; and,

• Nurse Portfolio Credentialing Commission.

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).

1. General

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. A/B MACs (B) 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.

3. Incident To

If covered CNS services are furnished, services and supplies furnished incident to the

services of the CNS may also be covered if they would have been covered when

furnished incident to the services of an MD/DO as described in §60.

4. Medical Record Documentation for Part B Services

This medical record documentation requirement applies to Part B professional services

that are paid under the Medicare physician fee schedule. Accordingly, for Part B Clinical

Nurse Specialist (CNS) covered services, the CNS may review and verify (sign and date),

rather than re-document notes in a patient’s medical record made by physicians,

residents, nurses, medical; physician assistant; nurse practitioner; clinical nurse specialist;

certified nurse-midwife; and certified registered nurse anesthetist students or other

members of the medical team, including as applicable, notes documenting the CNS’s

presence and participation in the service.

For documentation requirements specific to E/M services furnished by physicians and

certain nonphysician practitioners, see Chapter 12, section 30.6 of the Medicare Claims

Processing Manual, publication 100-04.

C. Application of Coverage Rules

1. Types of CNS Services

Examples of the types of services that CNS may provide are 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. State law or regulation

governing a CNS’ scope of practice for his or her service area applies.

2. Services Otherwise Excluded From Coverage

A CNS’ services are not covered if they are otherwise excluded from coverage even

though a CNS may be authorized by State law to perform them. For example, the

Medicare law excludes from coverage routine foot care and routine physical checkups

and services that are not reasonable and necessary for diagnosis or treatment of an illness

or injury or to improve the function of a malformed body member. Therefore, these

services are precluded from coverage even though they may be within a CNS’ scope of

practice under State law.

See §60.2 for coverage of services performed by a CNS incident to the services of

physicians.

D. Collaboration

Collaboration is a process in which a CNS works with one or more physicians (MD/DO)

to deliver health care services within the scope of the CNS’ professional expertise with

medical direction and appropriate supervision as required by the law of the State in which

the services are furnished. In the absence of State law governing collaboration,

collaboration is to be evidenced by the CNS documenting his or her scope of practice and

indicating the relationships that the CNS has with physicians to deal with issues outside

the CNS’ scope of practice.

The collaborating physician does not need to be present with the CNS when the services

are furnished or to make an independent evaluation of each patient who is seen by the

CNS.

E. Direct Billing and Payment

A CNS may bill directly and receive direct payment for their services.

F. Assignment Requirement

Assignment is required for the service to be covered.