Do Registered Nurses Need a National Provider Identifier (NPI)?

Tracy A. Klein, RN, MS, WHCNP, FNP

Disclosures

September 11, 2008

Question

I believe that registered nurses need to apply for NPI numbers in certain situations. Where and how can I learn more?

Response from Tracy A. Klein, RN, MS, WHCNP, FNP
Adjunct Clinical Faculty, Graduate Nursing, Washington State University, Vancouver, Washington; Nurse Practitioner -- Consultant, Oregon State Board of Nursing, Portland, Oregon

Response from Tracy A. Klein, RN, MS, WHCNP, FNP
Adjunct Clinical Faculty, Graduate Nursing, Washington State University, Vancouver, Washington; Nurse Practitioner -- Consultant, Oregon State Board of Nursing, Portland, Oregon


The National Provider Identifier (NPI) is a unique identifier number that applies to many types of healthcare providers. Unlike other numbers, such as the Drug Enforcement Administration (DEA) number required to prescribe controlled substances, the NPI is not restricted to prescribers, institutions, or licensed independent practitioners. Depending on where you work and the type of patients you see, as a registered nurse you may be required to obtain an NPI. Registration for an NPI can be done online free of charge. The following information will help you determine whether the newly implemented NPI requirement affects your practice.

History of the Need for an NPI

The NPI was developed with the goal of replacing several different billing numbers issued to healthcare providers with a single unique number. It was also hoped that the widespread use of the NPI could help resolve the inappropriate use of a prescriber's DEA number for insurance billing when medications that are not controlled substances are prescribed or dispensed. The requirement by many pharmacies for a DEA number before noncontrolled substances, such as antibiotics, were released to patients penalized many advanced practice nurses who chose to or were not able to apply for a DEA number under their state law.

Final rules with regard to who can and should apply for an NPI were published in the Federal Register on January 23, 2004.[1] Although the initial intent was to pilot the use of the NPI with Medicare claims, the actual implementation date was designated in phases. The compliance date for all covered entities except small health plans was May 23, 2007; the compliance date for small health plans was May 23, 2008.[2]

Purpose and Scope of the NPI

The primary purpose of the NPI is to identify a healthcare provider in standard transactions, such as billing for healthcare. According to the Centers for Medicare and Medicaid's (CMS) Frequently Asked Questions Web site: "NPIs may also be used to identify health care providers on prescriptions, in internal files to link proprietary provider identification numbers and other information, in coordination of benefits between health plans, in patient medical record systems, in program integrity files, and in other ways.[2]"

An NPI must now be used by all Health Insurance Portability and Accountability Act (HIPAA)-covered entities, including private insurance plans or providers. The NPI number is designed to stay the same throughout job or location changes.

What is a HIPAA-covered entity? A HIPAA-covered entity is defined as a healthcare provider who conducts transactions in electronic form, a healthcare clearinghouse, or a health plan.[3] CMS has published charts that help identify whether you or your employer meet the criteria for a covered entity that can be accessed online.[3]

There are several areas of overlap, which are referred to as "hybrid" entities. One of the most common of these is the large research university, where many healthcare research activities and nurses who participate in them are required to be covered by both individual and institutional NPIs. In this setting, see the HIPAA compliance office Web site for your university to obtain more information. One example of this resource is the comprehensive Web site provided by the UC Davis System.[4]

Who is eligible to apply for an NPI? According to the CMS' Frequently Asked Questions Web site:

In general, health care providers include hospitals, nursing homes, ambulatory care facilities, durable medical equipment suppliers, clinical laboratories, pharmacies, and many other "institutional" type providers; physicians, dentist, psychologists, pharmacists, nurses, chiropractors and many other health care practitioners and professionals; group practices, health maintenance organizations, and others.[2]

In many cases, a registered nurse may be required to obtain his or her own NPI.

What Does This Mean for Registered Nurses?

In many states, a registered nurse can own a business in his or her own name, known as a sole proprietorship. The owner of a sole proprietorship would apply for an NPI as an "individual[2]" if he or she has met the requirements as a HIPAA-covered entity. Small providers have special exemptions from HIPAA and NPI requirements,[2] so it is important to visit the NPI Registration Homepage or consult an attorney if you are unsure whether your business qualifies for an exemption.

A healthcare provider can only apply for 1 NPI. Business models that include corporation formation are defined differently from those that function as sole proprietorships, and may require a separate NPI number for the corporation itself. Contact your state Corporation Division, which is located under the Secretary of State or Department of State through your state government Web site, for more information.

Nurses who work in health research through large healthcare systems or health plans will be required, in most cases, to obtain their own NPIs. Nurses who participate in federally funded programs, such as those using Community HOME Investment Program (CHIP) funds, Medicaid, Medicare, or Title X Family Planning money, will also be required to obtain NPIs for their services, especially as public health clinics often bill the government for nurse-only provided services, such as immunizations, family planning counseling, and pregnancy testing.

Other circumstances that may require the nurse to obtain an NPI include occupational health, home health, long-term care, and any area in which nursing services are billed separately. Additionally, providers may apply for an NPI even if they are not required to do so, because it is possible that some of their services will fall under the requirements during the course of their daily duties.

Once implemented, the use of NPIs will have many potential benefits. The NPI will replace the need for possessing multiple identification numbers, and is retained through job and location changes throughout the health professional's career. However, the initial implementation process has been hampered by confusion and rejected claims as healthcare providers and institutions sort through the many levels of requirements. It would benefit registered nurses to periodically review the NPI requirements with their staff and/or employer to ensure that compliance is met for all covered entities and processes.

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