Nurse Practitioner (NP) Claims Submitted for Inpatient Hospital Admissions (2024)

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October 17, 2013 – Revised: 12.13.23

Nurse Practitioners, unless authorized by their state regulations, should not submit claims for inpatient hospital admissions (CPT Codes 99221 – 99223: Initial Hospital Care, New or Established Patient).

The CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 30.6.10 states, in part:

1. In the inpatient hospital setting, physicians (and qualified nonphysician practitioners where permitted) may submit the most appropriate initial hospital care code (CPT Codes 99221 – 99223, Initial Hospital Care, New or Established Patient).
2. The principal physician of record is identified in Medicare as the physician who oversees the patient's care from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier "-AI" (Principal Physician of Record), in addition to the E/M code.

Reminders:

• "Incident to" billing is not permitted in facility settings.
• NPs who do not have admitting privileges based on state regulations cannot bill for the admission.
• Medicare requires the admitting physician who submits HCPCS modifier AI assume all management of the patient's care during the inpatient hospital stays.
• If an NP sees patient in the morning and documents that visit, then the physician follows with a face-to-face later the same day, the physician's claim should be submitted with HCPCS modifier AI.
  • If the NP and physician are members of the same group and Medicare criteria are followed, this may be allowed as a "split/shared visit," and both the NPP and physician's notes may be considered for purposes of determining the level of service and CPT code.
• Documentation must be signed and dated by the author. If the physician's signature is not legible, his/her printed name must be provided near the signature. Ensure that the author's professional designation (e.g., NP, MD) is included with the signature.

References:

• "Incident to" billing not permitted in facility settings: CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 60.1.B
• Guidance for split/shared visits:
• CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, section 30.6.13.H
• Medicare guidance regarding signatures in medical records: CMS MLN Matters article MM6698, "Signature Guidelines for Medical Review Purposes"