The Balanced Budget Act of 1997: Reimbursement and the Advanced Practice Nurse

William J. Mazzocco Jr.


January 28, 2000

In This Article


  1. Obtain advanced practice nursing reimbursement policy statements from the major insurance providers that represent the bulk of your practice's reimbursement.

  2. Find out if those insurers permit "incident-to" billing and read all prospective provider contracts offered to your practice. Pay particular attention to key phrases like "physician only" or "physician may not delegate."

  3. Know the nursing scope of practice for your state. Don't base your practice on what is being done in another state.

  4. Learn how to use ICD-9 and CPT codes, and if you have not already applied for a Medicare Provider number do so now. Individual Medicare carriers will issue the provider application (form 855). You can ask specific questions at the HCFA Web site.

  5. Become competent in the use of E&M codes for professional services and expect to have your charts audited. Remember -- if you did not document the service, the assumption is that you did not do it!

  6. Learn how to avoid Medicare fraud and abuse pitfalls. Be particularly conscious of potential "double-billing," such as billing Medicare Part A (hospitals) and Medicare Part B (provider) for the same service on the same day, if you are employed by an institution.

  7. Monitor HCFA's regulatory proposals carefully by checking the Federal Register's National Archives and Records Administration Web site on a regular basis. Why pay consultants when you can get the information for free?

  8. Closely monitor your Medicare reimbursement from local carriers to ensure that they are not arbitrarily down-coding your service codes.

  9. Utilize the existing reimbursement appeals process and save all correspondence from the insurance carrier.

  10. Obtain an MSN as insurance against any future HCFA regulatory changes of heart.


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