PMHNP Billing And Coding
Can PMHNPs Bill Medicare?
Yes. Medicare recognizes PMHNPs as providers under Section 1861(aa) of the Social Security Act. You enroll through PECOS on the CMS-855I and bill under your own NPI at 85% of the physician fee schedule. Incident-to billing at 100% is the one exception, and its conditions are strict.
The Short Answer
Yes, PMHNPs Can Bill Medicare
Nurse practitioners, including psychiatric mental health nurse practitioners (PMHNPs), are statutorily recognized under Medicare. They’re defined in Section 1861(aa) of the Social Security Act, and their services are paid under the framework in Section 1833. A PMHNP who is licensed and enrolled can bill Medicare directly under their own National Provider Identifier (NPI) for covered psychiatric and mental health services that fall within their state scope of practice.
Getting Enrolled
How To Enroll And Bill
1. Get An NPI
Get a Type 1 (individual) NPI through the NPPES registry if you don’t already have one. Every clinician who bills Medicare needs one.
2. Enroll Via PECOS (CMS-855I)
Enroll as a Medicare provider using the CMS-855I application, typically submitted online through PECOS (Provider Enrollment, Chain, and Ownership System). Per CMS, the CMS-855I is the enrollment application for individual physicians and non-physician practitioners, including nurse practitioners.
3. Reassign Benefits (CMS-855R)
Billing through a group or practice? Then you’ll reassign your Medicare billing rights to that practice or organization. That’s the CMS-855R function, which links your enrollment to the group’s billing. In the current process, CMS has folded the 855R into the CMS-855I.
4. Bill Under Your NPI
Once approved, submit claims under your own NPI (or reassigned to your group). Medicare pays covered NP services at 85% of the physician fee schedule.
See the CMS Medicare Provider Enrollment resource and PECOS.
The Rate
What Medicare Pays: The 85% Rate
When a service is billed under the NP’s own NPI, Medicare pays 85% of the amount a physician would receive under the physician fee schedule for the same service, per 42 CFR 414.56. More precisely, Medicare pays 80% of the lesser of the actual charge or 85% of the physician fee schedule amount. The patient owes the remaining coinsurance. That’s consistent with Section 1833 of the Social Security Act.
The one way the same NP service is paid at 100% of the physician fee schedule is under the incident-to provision, which requires a physician-established plan of care, an existing problem, and billing under the physician’s NPI. For behavioral health services, Medicare allows general supervision, so the physician doesn’t have to be in the suite. Those conditions are strict. Our incident-to billing guide for PMHNPs has the details.
Scope
What You Can And Cannot Bill
Generally billable by a PMHNP (within state scope and payer coverage):
- Psychiatric diagnostic evaluation with medical services (90792)
- Medication management office visits (E/M codes 99202-99205 and 99212-99215)
- Individual psychotherapy (90832, 90834, 90837) and add-on psychotherapy with E/M (90833, 90836, 90838)
- Group psychotherapy (90853)
Key limits:
- You can only bill for services within your state scope of practice and your training. Medicare recognition doesn’t expand your state license.
- Services must be medically necessary and meet the coverage rules in your local Medicare coverage articles, such as the CMS Psychiatry and Psychology Services article (A57480).
- Some services require specific supervision or collaboration arrangements depending on state law.
Beyond Medicare
Medicaid And Commercial Coverage
Medicaid Varies By State
Each state administers its own Medicaid program, so PMHNP enrollment, covered services, reimbursement percentages, and supervision or collaboration requirements differ significantly from state to state. Your state Medicaid provider manual has the rules.
Commercial Once Credentialed
Commercial insurers generally reimburse PMHNPs once you’re credentialed and contracted with each plan. Panels, fee schedules, and whether the plan credentials NPs directly vary by payer, so credentialing with each network is the gate to getting paid.
FAQ
Frequently Asked Questions
Can A Psychiatric Nurse Practitioner Bill Medicare Directly?
Yes. PMHNPs are recognized under Section 1861(aa) of the Social Security Act and, once enrolled through PECOS, can bill Medicare directly under their own NPI for covered services within their state scope of practice.
What Form Do I Use To Enroll A PMHNP In Medicare?
Individual nurse practitioners enroll with the CMS-855I application, usually submitted online through PECOS. To bill through a group, you also reassign benefits (the CMS-855R function, now merged into the 855I).
How Much Does Medicare Pay A PMHNP?
When billed under the NP’s own NPI, Medicare pays 85% of the physician fee schedule amount for the service (specifically, 80% of the lesser of the actual charge or 85% of the fee schedule), per 42 CFR 414.56. Incident-to billing under a physician’s NPI is paid at 100% when its conditions are met.
Does Medicaid Cover PMHNP Services?
Usually, but it varies by state. Medicaid is state-administered, so enrollment, covered services, and reimbursement rates for PMHNPs differ. Check your state Medicaid provider manual for specifics.