CMS Pub. 100-04, ch. 12, § 130.1

Payment for certified nurse-midwife (CNM) services is made directly to CNMs for their

professional services, and for services furnished incident to their professional services.

Also, CNMs are required to accept assigned payment for their services. Accordingly,

when CNMs bill for their services under specialty code 42, billing does not have to flow

through a physician or facility unless the CNM reassigns their benefits to another billing

entity. For reassigned CNM services, the entity bills for CNM services using the

specialty code 42 to signify that payment for CNM services is being claimed.

Prior to December 31, 1991, Medicare Part B payment for CNM services was made at 80

percent of the lesser of the actual charge or, under a fee schedule that did not exceed 65

percent of the prevailing charge. This payment methodology changed and effective

January 1, 1992, until December 31, 2010, payment for CNM services is made at 80

percent of the lesser of the actual charge, or 65 percent of the physician fee schedule

amount for the same service performed by a physician. However, effective on and after

January 1, 2011, payment for CNM services is made at 80 percent of the lesser of the

actual charge, or 100 percent of the physician fee schedule amount for the same service

performed by a physician.

Payment for covered drugs and biologicals furnished incident to CNMs’ services is made

according to the Part B drug/biological payment methodology. Covered clinical

diagnostic lab services furnished by CNMs are paid according to the clinical diagnostic

lab fee schedule. Also, when CNMs furnish outpatient treatment services for mental

illnesses, these services could be subject to the outpatient mental health treatment

limitation (the limitation). The appropriate percentage payment reduction under the

limitation is applied first to the approved amount for the mental health treatment services

before the actual payment amount is determined for the CNMs’ services. Please refer to

§210 of this manual to determine the appropriate percentage payment reduction under the

limitation.