C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 414—PAYMENT FOR PART B MEDICAL AND OTHER HEALTH SERVICES › Subpart B—Physicians and Other Practitioners

42 C.F.R. § 414.56

Payment for nurse practitioners' and clinical nurse specialists' services

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(a) Rural areas. For services furnished beginning January 1, 1992 and ending December 31, 1997, allowed amounts for the services of a nurse practitioner or a clinical nurse specialist in a rural area (as described in section 1861(s)(2)(K)(iii) of the Act) may not exceed the following limits:

(1) For services furnished in a hospital (including assistant-at-surgery services), 75 percent of the physician fee schedule amount for the service.

(2) For all other services, 85 percent of the physician fee schedule amount for the service.

(b) Non-rural areas. For services furnished beginning January 1, 1992 and ending December 31, 1997, allowed amounts for the services of a nurse practitioner or a clinical nurse specialist in a nursing facility may not exceed 85 percent of the physician fee schedule amount for the service.

(c) Beginning January 1, 1998. For services (other than assistant-at-surgery services) furnished beginning January 1, 1998, allowed amounts for the services of a nurse practitioner or clinical nurse specialist may not exceed 85 percent of the physician fee schedule amount for the service. For assistant-at-surgery services, allowed amounts for the services of a nurse practitioner or clinical nurse specialist may not exceed 85 percent of the physician fee schedule amount that would be allowed under the physician fee schedule if the assistant-at-surgery service were furnished by a physician.

[63 FR 58911, Nov. 2, 1998]
Notes of Decisions
Cited in 2 cases (2 in the last 5 years), 2022–2025 · leading case: Robert O'Laughlin v. Radiation Therapy Servs. (6th Cir. 2025).
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Robert O'Laughlin v. Radiation Therapy Servs. (6th Cir. 2025). · cites it 2× “42 C.F.R. §§ 414.56, 414.52. But when a physician performs the same service, CMS will reimburse the full amount.”
O'Laughlin v. Radiation Therapy Servs., P.S. C. (E.D. Ky. 2022). “” 42 C.F.R. §§ 414.56 (c) and 405.520(a). Additionally, Defendants’ argument that “chemotherapy is a service performed by auxiliary personnel” and that physician supervision is not necessary may be true, but it does not refute the argument that those services would be capped at…”
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