CMS rule creates reimbursement opportunities for RNs

By | 2022-02-23T14:24:58-05:00 November 15th, 2012|8 Comments

The American Nurses Association touted a new Medicare rule that calls for paying advanced practice RNs for primary care services intended to effectively manage patients’ transitions from hospitals to other settings while preventing complications and conditions that lead to expensive hospital readmissions.

The rule also creates new payment codes for care coordination activities performed by RNs that reduce costs and improve patient outcomes, increasing the likelihood of direct reimbursement for these services and potentially creating more RN jobs to fill this need. (For more information, see the PDF at and go to page 282 for the section on transitional care.)

With up to 20% of Medicare patients readmitted to hospitals within 30 days of discharge, more value has been placed on effective transitional care and care coordination. “The American Nurses Association has been advocating for years that government and private insurers need to recognize nurses’ contributions to transitional care and care coordination and pay appropriately for these essential services,” ANA President Karen A. Daley, RN, PhD, MPH, FAAN, said in a news release. “This Medicare rule is a giant step forward for nurses whose knowledge and skills play major roles in patients’ satisfaction and quality of care.”

The ANA’s 2012 report, “The Value of Nursing Care Coordination” (, highlighted numerous studies showing the positive impact of nurse-managed care coordination. Studies have showed that care coordination reduces ED visits, hospital readmissions and medication costs; lowers total annual Medicare costs; improves patient satisfaction and confidence to self-manage care; and increases safety for older adults during transitions between settings.

The ANA participates on the American Medical Association’s Current Procedural Terminology and Relative [Value] Update Committee panels that set codes describing medical, surgical and diagnostic services and place price values on them. These codes are the foundation for the Centers for Medicare & Medicaid Services’ payment policies.

“There’s no doubt that the ANA’s involvement on these panels had a strong influence on the new provisions that account in real dollars for nurses’ crucial contributions,” Daley said. “Patients benefit from our work. Now the value of our work is being recognized through payment policy.”

New payments will be awarded to nurse practitioners, clinical nurse specialists, certified nurse midwives and other primary care professionals for “transitional care management” services provided within 30 days of a Medicare patient’s discharge from a hospital or similar facility.

To qualify for reimbursement, the primary care professional must contact the patient soon after discharge, conduct an in-person visit, engage in medical decision-making and provide care coordination. Care coordination involves effectively communicating and delivering a patient’s needs and preferences for health services and information among a continuum of healthcare providers, functions and settings.

The Medicare Physician Fee Schedule Final Rule, set to take effect Jan. 1 after publication in the Federal Register, also includes new codes that describe “complex chronic care coordination,” a service typically provided by RNs.

Although the rule does not allow separate billing for care coordination, some private insurers likely will use the codes to reimburse providers directly for the service, the ANA noted. Such reimbursement policies for care coordination could expand the RN job market and raise recognition for nurses performing this long-held, core professional standard and competency that is considered integral to patient-centered care and the effective and efficient use of healthcare resources, according to the ANA.

The rule contains several other provisions that benefit nurses by clarifying that certified registered nurse anesthetists will continue to be reimbursed for providing chronic pain management services in states where permitted by license; allowing APRNs to order portable X-rays; and ensuring nurse practitioners and clinical nurse specialists can conduct the in-person encounters required for ordering durable medical equipment for patients.


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  1. Avatar
    Ashley Brazzell April 2, 2018 at 10:35 pm - Reply

    Can a registered nurse be reimbursed for in-home preoperative and postoperative education?

    • Avatar
      Marsha May 24, 2018 at 11:12 am - Reply

      good question! I would like to know the same.

    • Avatar
      Mitch September 23, 2018 at 6:41 am - Reply

      Hi Ashley,

      Have you been able to find how a RN can be reimbursed for in-home preoperative and postoperative education? Please let me know. [email protected]

  2. Avatar
    Kathleen Dean June 8, 2018 at 4:15 am - Reply

    How can a registered nurse submit and get paid through Medicaid and Medicare for Case management ? Specifically, the steps to bill ?

  3. Avatar
    matt August 5, 2018 at 6:00 pm - Reply

    hi kathleen,

    I am looking for the same information. I just got my NPI number. I am now looking to work on my own rather than a home care agency and would like to know the next steps. I have not been able to find any easy answers and i dont know anyone who actually does it. I am also looking into getting my PRI and Screen. Looks like you probably already have them since you are inquiring about case management.

    if you figure it out or want to brainstorm message me. this goes for anyone else as well.

    [email protected]

    RN in Upstate NY.

  4. Avatar
    Deborah Magnin August 16, 2018 at 7:58 pm - Reply

    Hello…I have an NPI number …how would I obtain reimbursement for case management, disease management, TRANSITION of care case management for Medicare beneficiaries?

  5. Avatar
    Dianne Matthews February 3, 2019 at 2:39 pm - Reply

    I’m an RN , and due to injury saving a patient from falling. I shattered myL5vertebrae. I am ? starting a nurse advocate business. I need to know how to bill Medicare/ medicade. I found info. Saying I can just not how?? Please let me know thank you Dianne Matthews

  6. Avatar
    Joyce May 16, 2020 at 6:33 pm - Reply

    WOW, has anyone found the answer to how to bill

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