Nurse Navigator

Good morning.

One of our clinics just hired an RN for their office in a Nurse Navigator role. From what I have been told, she is providing counseling/education/coaching (ex; Diabetes, Obesity). The clinic is wanting to bill for her services.

My initial thoughts after some researching is incident to does not apply and after reading an example of one of the notes, complex chronic care management do not seem appropriate either. If the nurse visit requirements are met would this be our only option? She had read in Medicare regulations somewhere services can be billed as "auxiliary personnel".

I would appreciate any suggestions and/or what others are billing.

Lisa Hook, CPC, LPN
Certified Professional Coder


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  • Her services may be billed by a supervising physician/qualified NPP as 99211 (not as any other E/M code, as E/M codes other than 99211 represent the work of physicians/qualified NPPs):

    * if the services were performed in a physician office setting where the nurses are employed by the physician office/practice (not in an outpatient hospital clinic where the nurses are employed by the facility),

    * if the patient was indeed established, and

    * if the situation met incident-to billing rules, meaning the nurse counseling was:

    o incidental to an earlier service by a billing provider at which time that provider saw the patient initially, diagnosed the problem, and formulated a management plan that included counseling to be provided by a nurse

    o provided while a billing provider (not necessarily the same as the original provider) was in the office suite and available to assist if necessary

    Seth Canterbury, CPC, CPC-I
    Clinical Data Quality Education Department
    University of Florida Jacksonville Physicians, Inc.
    653 West Eighth Street
    Tower I, Suite 606
    Jacksonville, FL 32209
    (912) 227-5965

  • edited June 2017

    Be sure to work with your major contracted plans to determine how they would
    like the services reported. From what I know, this type of position is paid
    through facility fees, like nursing, assistants, etc. Bringing it into
    private practice puts you at a disadvantage for proper and correct
    reimbursement to cover costs.

    Before settling on a Medicare rule for payment, look in the Medicine section
    of CPT and work with the person developing the position's job description.
    (99211 will not cover the expense, even with the patient's co-insurance
    and/or copay.)

    Define some codes that explain accurately what is being provided and work
    with the health plan representatives to determine which one(s) can apply and
    if they can consider a reimbursement schedule.

    Good luck,

    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219-0409

    Tel: (941) 776-4822

    Fax: (240) 368-0059


    Since 1996, Celebrating 20 years of Service to Physicians

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