Billing for Psychiatric Clinical Nurse Specialists Services Within the Medicare Program

Janet Garvey Baradell, PhD, RN, CS, Carolyn Buppert, NP, JD


Topics in Advanced Practice Nursing eJournal. 2003;3(1) 

In This Article


Medicare pays the CNS or, if the CNS reassigns payments to an employer, Medicare pays the CNS's employer. For evaluation/management and consultation services, Medicare pays psychiatric CNSs (as well as other CNSs, nurse practitioners, and physician assistants) 85% of 80% the physician rate for a service, as listed in the Medicare physician fee schedule for the current year. The patient pays 20% of the fee as a copayment. Psychotherapy services are subject to a 50% outpatient psychiatric benefit limitation (also referred to as an outpatient psychiatric reduction). The patient is responsible for 50% of the fee for psychotherapy.

Payment Examples

Payment example -- psychotherapy service. In North Carolina the Medicare Fee Schedule payment for a 45-minute, outpatient psychotherapy service (CPT code 90806) is $91.45. The approved amount for a psychiatric CNS is $77.73. Applying the 50% outpatient psychiatric reduction, Medicare would pay the CNS $38.87, assuming that the patient has met the annual deductible. The CNS must collect any applicable copayment from the patient, in this case, $38.86. The outpatient psychiatric benefit reduction does not apply to inpatient psychiatric care. For services furnished in the hospital, CNSs are reimbursed at 85% of the physician fee schedule.

Payment example -- evaluation and management service. In North Carolina, the Medicare Fee Schedule payment for CPT code 90801 is $138.03. The approved amount for a CNS (at 85% for the fee schedule amount) is $117.33. Medicare would reimburse the nurse 80% of this amount, or $93.86. The patient is responsible for the copayment of 20% of the fee schedule amount, in this case, $23.46.

The fee schedule amounts vary from state to state. Medicare calculates the rates using formulas that take into account differences in practice expenses.