Certified nurse-midwives (CNMs) are RNs with advanced training and certification in midwifery. These advanced practice nurses are recognized in all 50 states as a legal profession. A CNM licensed RN, can care for expectant mothers and, provide clinical OB/GYN services. This includes oversight of prentatal care during pregnancy; management of labor; delivery of the infant, and postnatal care of moms & babes, and some even teach breastfeeding techniques, and provide assistance with post-partum depression. CNM’s also provide preventive health care / wellness visits to include pap smear testing, counseling, prescribing of diagnostic & therapeutic medications, conducting clinical research and trials, diagnostic testing such as ultrasound, cytometrogram’s and minor procedures such as lesion removals and biopsy’s. The value of such an employee is that they can provide nearly identical services as an MD/DO OB/GYN, yet do not raise the practice overhead expense at the same level as a MD/DO OB/GYN employee.
CNM services encompass a full range of ancillary services that can be incorporated into an OB/GYN practice. CMS allows (Center for Medicare/Medicaid Services) CNM’s to provide full scope of care and in the past have been reimbursed from 65- 85% allowable of the Medicare Physician based fee schedule.
Prior to April 1, 2008, if the CNM service was provided as “incident to” an MD or DO, reimbursement was figured and paid at 100% of CMS Medicare/Medicaid allowable fee schedule. However, As of April 1, 2008, Under under H.R.3126, CNM' s will now be paid at 100% of the Medicare Allowable fee schedule. The current Medicare fee schedules include all MD/DO’s, chiropractors, optometrists, podiatrists, nurse-anesthetists, audiologists, and speech language pathologists.
Below outlines some of the criteria necessary to bill correctly for the CNM.
Documentation Criteria: CNM must personally document, date and signs all entries (e.g., chief complaint or reason for visit, history, exam, services rendered, care plan). Diagnoses are required for all rendered/ordered services. In some states, the supervising MD must countersign non-MD entries, or have a supervisory protocol/clause/standard of practice in place regarding the oversight of care provided by the CNM. .
Evaluation and Management: CNM’s may utilize codes 99201-99205, and codes 99211-99215 for services performed in the physician office, and the CNM has their own UPIN/NPI number to bill under. However, if the services are provided as “incident to”, then billing of a claim for payment must be made under the supervising physician’s UPIN/NPI and billed at full fee schedule.
Consultations: The CNM can request a consultation from an outside provider. However, if the CNM is providing a “consultation” then they are recognized as a “general practitioner” providing expertise, not as a “specialty provider” {i.e. OB/GYN specialty) providing expertise. So you will need to have clear documentation when billing a consultation codes for a CNM. Consultation codes 99241-99245 can be billed if documented clearly in the medical record. (providing all criteria is met, however, CPT still includes consultation codes in the CPT manual, however, CMS no longer recognizes or pays on the consultation codes, and many private or 3rd party payers will not recognize them or pay if billed with them.
Diagnostic Testing and Procedures: CNM’s can request and perform diagnostic testing, and procedures however, these are subject to the individual scope of practice for the state in which the CNM is practicing in. The scope of practice can vary widely from state to state. Most CNM’s perform the full scope of pre-natal, vaginal delivery, and post-partum care for OB services and do the same for private payors. However, CNM’s do not provide cesarean delivery services.
Designation HCPCS Modifier SB: Some payors or insurance carriers may require the addition of the modifier “SB” appended to the base code to designate that the service was provided by a CNM. However, this is becoming less and less common, as the NPI number should designate to the intermediary or clearing house that the service was rendered by a CNM. Some smaller payors however, still require hard copy claims, in which the SB modifier may be needed on the claim before they will process your request for payment.
OB Prenantal/Delivery/Postpartum Packages: Most CNM’s are employees of a private practice, and are paid a flat, hourly salary. However, some CNM providers are paid on a case-by-case global billing code, based upon the RBRVS payment for physicians. In some OB/GYN practices, if the CNM provides the Antenatal, vaginal delivery, and post-partum care they can bill the OB/GYN “global package” (i.e. code 59400) . However, if they do the antenatal, and post-partum care but the MD/DO does the cesarean section, you will only bill for the services rendered.
In some practices, CNM’s are used as a “physician extender” where the CNM see’s and evaluates the patient prior to the patient ever meeting the MD/DO. In other practices, CNM’s may only provide the antenatal and post-partum care, then MD/DO OB/GYN will perform the delivery. (regardless of what type of delivery it may be) In other practice scenario’s, the CNM has the MD/DO meet with the patient, in case a cesarean is required. CNM's can also be an assist at surgery for a OB surgeon. If they are working as the assist at surgery, be sure to append modfier AS, not modfier 80/81. Modifier AS was created by HCPCS to specify an non-MD/DO provider.
The best way to code and bill for the CNM is to follow the coding convention guidelines carefully. Global pregnancy package guidelines and state payors may have different criteria, so you should always pre-authorize CNM services by the insurance payor to make sure that you’ll get paid.
HAPPY CODING... As always, if you have questions, please feel free to contact me.
