Clinical Nurse Specialists

Leaders in Managing Patients With Chronic Conditions

Mary P. Hansen; Mitzi M. Saunders; Cynthia R. Kollauf; Ludmila Santiago-Rotchford


Nurs Econ. 2019;37(2):103-109. 

In This Article

CNS Reimbursable Care

The ability of providers to contribute to the revenue stream is an important construct of healthcare economics. CNSs are among providers approved for billing through CMS. Table 1 highlights reimbursable CNS behaviors. Medicare accepts billing for CNSs who are licensed by the state, have a master or doctorate-level degree in nursing, are certified by a nationally recognized credentialing body, and employed at a facility that accepts Medicare payments. CMS introduced codes for Chronic Care Management and Complex Chronic Care, recognizing the systematic assessment, comprehensive care planning, and complex care coordination required for patients with chronic conditions. CNSs are designated providers allowed to use these codes (CMS, 2017). Efforts on the part of administrators and CNSs to understand details of billing related to chronic conditions are imperative to maximizing opportunities that generate revenue. Direct care provided by a CNS is reimbursable by agencies such as CMS at 85% of the physician rate. This is a substantial generation of revenue and cost savings in markets where lack of PCPs has led to overutilization of services in the acute care setting (Fraser & Melillo, 2018).