C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED › Subpart E—Criteria for Determining Reasonable Charges

42 C.F.R. § 405.520

Payment for a physician assistant's, nurse practitioner's, and clinical nurse specialists' services and services furnished incident to their professional services

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(a) General rule. A physician assistant's, nurse practitioner's, and clinical nurse specialists' services, and services and supplies furnished incident to their professional services, are paid in accordance with the physician fee schedule. The payment for a physician assistants' services may not exceed the limits at § 414.52 of this chapter. The payment for a nurse practitioners' and clinical nurse specialists' services may not exceed the limits at § 414.56 of this chapter.

(b) Requirements. Medicare payment is made only if all claims for payment are made on an assignment-related basis in accordance with § 424.55 of this chapter, that sets forth, respectively, the conditions for coverage of physician assistants' services, nurse practitioners' services and clinical nurse specialists' services, and services and supplies furnished incident to their professional services.

(c) Civil money penalties. Any person or entity who knowingly and willingly bills a Medicare beneficiary amounts in excess of the appropriate coinsurance and deductible is subject to a civil money penalty as described in §§ 402.1(c)(11), 402.105(d)(2)(viii), and 402.107(b)(8) of this chapter.

[63 FR 58905, Nov. 2, 1998, as amended at 66 FR 49547, Sept. 28, 2001]
Notes of Decisions
Cited in 4 cases (1 in the last 5 years), 2002–2025 · leading case: United States v. Marder, 208 F. Supp. 3d 1296 (S.D. Fla. 2016).
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United States v. Marder, 208 F. Supp. 3d 1296 (S.D. Fla. 2016). “2010) (citing 42 C.F.R. §§ 405.520 (a), 414.52, 414.56); see also U.”
Landau v. Lucasti, 680 F. Supp. 2d 659 (D.N.J. 2010). · cites it 2× “42 C.F.R. § 405.520 (a). Both Section 414.”
US Ex Rel. Schuhardt v. Washington Univ., 228 F. Supp. 2d 1018 (E.D. Mo. 2002). “See 42 C.F.R. § 405.520 and 405.521 (1967). Under the provisions of these regulations, a physician in a teaching setting was considered the attending physician for a Medicare patient, and thereby qualified for Medicare Part B reimbursement only if he or she furnished "personal…”
Robert O'Laughlin v. Radiation Therapy Servs. (6th Cir. 2025). · cites it 2× “See 42 C.F.R. § 405.520. When a nurse practitioner or physician assistant performs a service, CMS will reimburse up to 85% of the amount payable to a physician.”
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