This implies that APNs should know the federal and state laws, rules, and regulations that clearly define their scope of practice and prescriptive authority. Maintaining that argument can devastate the practitioner's career, even if the case is dismissed from court or the practitioner is acquitted of malpractice. Retrieved from: https://www.govinfo.gov/content/pkg/STATUTE-91/pdf/STATUTE-91-Pg1485.pdf, U. S. Congress. Split/Shared Services are an encounter where a Physician and a NPP each personally perform a portion of the E&M visit. Plager K. A., Conger M. M (2007). HELENA, Mont. There are more than 355,000 nurse practitioners (NPs) licensed in the U.S. 1. Patient Protection and Affordable Care Act. Although CMS rules refer to Medicare billing, other insurance companies often base their billing practices on CMS guidelines (Edmunds, 2014). For that reason, the AMA has designated several specific code numbers for reporting unlisted services/procedures, which should be described using the section specific guidelines. The CPT codes are updated annually to include new services and/or procedures and to remove obsolete ones. During this same time, there was a surge of NPs and PAs. (MedPAC, 2019a). Under incident to payment, a non-physician provider (NPP), such as an NP, certified nurse midwife (CNM) or physician assistant (PA), renders the care, but the visit is billed under the physicians name. Hospital discharges are billable if the service includes performing the final examination of the patient, discussion of the hospital stay, instruction for continuing care to all caregivers, prescriptions and referral forms and preparation of discharge records. The COVID-19 pandemic opened a need for NPs to provide a greater amount of care in more settings, and thus led to temporary removals of practice restrictions to increase access to care. Credentialing: A method to document recognition and verification of a provider's qualifications to practice in a health care setting. The Centers for Medicare and Medicaid Services (CMS) also expanded the roles of NPs, allowing them to provide services previously only permitted by physicians (Zolot, 2020) (See Tables 1 and 2). 24/7 Coverage - During the policy period, coverage is in force 24/7. . Additional and more rigorous research is needed. Impact of COVID-19 Pandemic on Nurses: Where is the Financial Safety Net? CPT codes are developed, maintained, and copyrighted by the American Medical Association (AMA). From the desk of the ACNP Health Policy Director. The Pediatric Nursing Certification Board (formerly National Certification Board of Pediatric Nurse Practitioners and Nurses). Nurse lobbying groups compromised on the NP reimbursement rate of 85% of the physician fee because the location restriction for NP care was removed. There are three key components required when selecting the appropriate level of E&M service provided: history, examination, and medical decision making. Almost 90% of NPs are certified in primary care and 69% actually provide primary care.In 2015, 1,965 medical students chose primary care residencies. Incident to billing practices are still in effect today. NPs have proven their care is on par with physician care, Penn Nursing educator says. The hospital cannot bill Medicare if the APRN's salary is being reimbursed under Part A of Medicare.1,2. A national survey of nurse practitioners' patient satisfaction outcomes. A new Penn Nursing article argues that payment parity is essential. These studies demonstrated outcomes comparable to, and sometimes better than, physicians. Note that to qualify for a given type of medical decision-making, two of the three elements must either be met or exceeded. Currently, there is no uniform model of regulation of APRNs across the states. General billing requirements in Medicare claims processing manual section 30.3.12.1. If a medical lawsuit is filed naming an individual practitioner along with the facility, the practitioner's interests in the defense may differ greatly from those of the facility/employer, who must protect its own reputation and finances. The process varies between facilities but may include completion of an application for credentialing and privileging, primary source verification of credentials, review board and approval. With the second method, Medicare, the nursing practitioner receives 80% of the fee that is set by the practice. COVID-19 has led to even more states temporarily removing restrictions on NP practice as an effort to increase patient access to care (Zolot, 2020). According to AANP (2020), as of February 2020, there are over 290,000 licensed NPs in the United States (US). However, with nurse managed clinics, the overhead cost may need to be re-examined (See Tables 1 and 2). This section will cover current procedure terminology, evaluation and management codes will follow. Workforce and reimbursement data were collected from a 2018 survey of Washington state advanced registered nurse practitioners (ARNPs). This policy helps cover the costs of injuries and property . There is a crucial need to equate the primary care reimbursement for all primary care providers. In June 2019, MedPAC again addressed payment policies for NPs and PAs. As the number of NPs continued to rise, removing the location barrier was a great feat (Apold, 2011). The numbers keep growing with over 28,700 recent graduates in 2018 (AANP, 2020). Medicare is a defined benefit category program. Retrieved from: http://www.medpac.gov/docs/default-source/reports/jun02_NonPhysPay.pdf?sfvrsn=0, Medicare Payment Advisory Commission (MedPAC). MedPAC estimates a savings of $50 million to $250 million in the first year. Quality of CareThroughout the fight for NPs to receive reimbursement from CMS, the quality of care that NPs provide has been studied extensively. COVID-19 brings changes to NP scope of practice. Number of nurse practitioners hits new record high. News-Medical.Net provides this medical information service in accordance This makes the NP invisible from the billing standpoint and can make it difficult to accurately identify patients who received care provided by NPs (Rapsilber, 2019) (See Table 2). The employer would retain the right to file a complaint against the practitioner to his/her licensing body (i.e., the state's Board of Nursing). Modifiers can also be added to CPT codes as a means of reporting or indicating that a service/procedure rendered has been altered by some specific circumstance but that it did not change the definition or code. CMS argues that a disparity exists between physician and NP payment because physicians have higher training cost, they are responsible for the overhead office cost, and they pay higher malpractice premiums. The 85% rule is particularly detrimental to NPs who own their own practice. If the APRN leaves the employment of the facility/agency, does the policy cover for an incident that occurred while still employed (is the employer's policy Occurrence)? However, without a physician on-site, NPPs were unable to receive any reimbursement for their services. Add on codes describe additional intra-service work associated with the primary procedure and must be performed by the same provider. Recognition of this productivity by both parties is crucial for NPPs to receive parity for equal services. Their conclusion was that the two groups actually produce different products, because NPPs tend to care for the less complex patients, and certain procedures could only be done by physicians (See Tables 1 and 2). In June 2002, they voted unanimously to increase CNM reimbursement from 65% to 85%. When subcutaneous tissue is debrided from a 16 sq cm dehisced abdominal wound and a 10 sq cm thigh wound, report the work with 11042 for the first 20 sq cm and 11045 for the second 6 sq cm. Current procedural terminology (CPT) codes are a systematic listing and coding of procedures/services performed by providers that serve as the basis for health care billing. The modifiers allow medical practitioners to effectively respond to payment policy requirements established by other entities. A NPI is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). Survey results will be used to improve workforce planning and advocate for payment parity legislation requiring health plans to pay ARNPs the same as physicians for the same service. All rights reserved. With the number of medical students going into primary care residencies on the decline, a shortage of 52,000 primary care physicians is expected by 2025 (Fodeman & Factor, 2015). Their role in healthcare has also evolved. The total length of time of the encounter should be documented and the record should describe the counseling and/or activities to coordinate care. The term provider will include the APRN and the physician. Resources: Family Nurse Practitioner Private Practice Family care is the most common specialization among nurse practitioners, with nearly 70% of NPs holding their primary certification in this area, according to AANP. Services are the type considered physician's services if furnished by a medical doctor or a doctor of osteopathy, Services are not otherwise precluded due to a statutory exclusion, and. For example, rounding is a physician service but not billable. APN reimbursement, April 15, 2009 Presentation by Christa Liley-Kennedy Group Enterprises, Inc. personal communication. Journal of Wound, Ostomy and Continence Nursing, Get new journal Tables of Contents sent right to your email inbox, http://www.gpo.gov/fdsys/pkg/PLAW-105publ33/pdf/PLAW-105publ33.pdf, http://www.medscape.org/viewarticle/562664_print, http://www.medscape.com/viewarticle/531035, https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf, http://www.cms.gov/MLNProducts/downloads/Medicare_Information_for_APNs_and_PAs_Booklet_ICN901623.pdf, http://www.cms.gov/manuals/downloads/pim83c15.pdf, https://www.cms.gov/MedicareProviderSupEnroll/, http://edocket.access.gpo.gov/cfr_2005/octqtr/pdf/42cfr410.21.pdf, https://www.cms.gov/manuals/downloads/clm104c01.pdf, http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf, http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf, http://www.trailblazerhealth.com/Publications/Training%20Manual/EvaluationandManagementServices.pdf, http://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf, http://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp, http://www.cnaptexas.org/displaycommon.cfm?an=1&subarticlenbr=17, http://www.ispub.com/journal/the_internet_journal_of_advanced_nursing_practice/volume_9_number_1_3/article/advanced_practice_nursing_constraints_to_role_fulfillment.html, Reimbursement of Advanced Practice Registered Nurse Services: A Fact Sheet, Understanding Medicare Part B Incident To Billing: A Fact Sheet, Ankle Brachial Index: Quick Reference Guide for Clinicians, Introduction to Reimbursement of Advanced Practice Registered Nurse Services and Understanding Medicare Part B Incident to Billing, The CAUTI Prevention Tool Kit: A Professional Practice and Collaborative Project of the Wound, Ostomy and Continence Nurses Society, 2021 Guideline for Management of Patients With Lower-Extremity Wounds Due to Diabetes Mellitus and/or Neuropathic Disease: An Executive Summary, Privacy Policy (Updated December 15, 2022), by the Wound, Ostomy and Continence Nurses Society. The COVID-19 pandemic has demonstrated how removal of practice restrictions can increase the care NPs can deliver, while maintaining quality. Documentation of the service must conform to the payer's requirements for the procedure code billed. Because visits that are billed incident to are reimbursed at 100%, and visits billed under an NP provider number are billed at 85%, Medicare would save a substantial amount of money by eliminating incident to billing. Conflict of interest can arise between the APRN and the employer itself. If billing is done via incident to services, these claims must be submitted under the supervising physician's NPI and identified on provider file by specialty code 50 for nurse practitioners and 89 for clinical nurse specialists. Portable Coverage - Take it with you. Past and present diagnoses should be easily accessible to the treating and consulting providers. Below is a chart that lists the elements of each level of medical decision making. A private insurer may use fee-for-service or capitation as its model for paying for Part A and Part B services on behalf of its enrolled beneficiaries. When an E&M is shared between a physician and APRN from the same group practice and the physician provides any face to face portion of the E&M encounter with the patient, the service may be billed under the physician's or the APRN's NPI number. Lessons learned from advanced practice nursing payment. The COVID-19 pandemic serendipitously led to the removal of many restrictions on NP practice, offering an opportunity for NPs to work with MedPAC to achieve full reimbursement for care provided. 2023 American Nurses Association. Medicaid: State administered program for low-income families and children, pregnant women, the aged, blind and disabled and long-term care. The APRN Consensus Model defines advanced practice registered nurse practice, describes the APRN regulatory model, identifies the titles to be used, defines specialty, describes the emergence of new roles and population foci, and presents strategies for implementation. Primary care physician office visits drop by 18%. Given the increased role of NPs, and their ability to provide care comparable to physicians, Congress should allow Medicare to increase the NP reimbursement rate to equate to 100% of the physician pay rate. L. No 105-33, Stat. Does the APRN have individual limits of liability? Since the pandemic began, several states have voted to permit permanent full practice authority to NPs. Indirect ReimbursementThe Omnibus Budget Reconciliation Act (OBRA) (1990) further supported NPPs by providing direct reimbursement for care in rural areas and indirect reimbursement for care in nursing homes, at 85% of the physician rate (Sullivan-Marx, 2008). The NPI has replaced the unique provider identification number (UPIN) as the required identifier for Medicare services, and is used by other payers, including commercial healthcare insurers. E&M Services: Evaluation and management services are CPT codes which describe physician-patient encounters are often referred to as Evaluation and Management Codes. See the 2021 rate information. Centers for Medicare & Medicaid Services (CMS). Payment Basics. If all four wounds were debrided on the same day, use modifier 59 with 11042, 11045, and 11044.11, 11042: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed): first 20 sq cm or less.11045: Each additional 20 sq cm, or part thereof. Primary Care Providers by the NumbersThe Affordable Care Act (2010), which President Obama signed into law in 2010, provided access to healthcare for millions of uninsured Americans. Recognition of this productivity by both parties is crucial for NPPs to receive parity for equal services.A study conducted by the RAND corporation found that the average cost of an NP visit was 20-35% lower than that of a physician visit (Naylor & Kurtamam, 2010). Credentialing and Privileging Provider credentialing and privileging is a practice in which documented recognition and verification is administered to a practicing professional. AWV. An example is if the APRN sees the patient in the morning and the physician performs a face to face in the afternoon on the same day, the physician or the APRN may report the service. . For example, if the annual practice premium costs $10,000 during the last year of coverage, the tail coverage could cost $15,000 to $20,000. Some procedural codes are commonly carried out in addition to the primary procedure performed. Has a Master's degree in nursing or a Doctor of Nursing Practice degree. With the second method, Medicare, the nursing practitioner receives 80% of the fee that is set by the practice. To be prepared to participate in today's health care industry, APRNs need to be competent clinicians but also need to be well versed in the business side of providing care. Figure. 3. 2005. How are Women Emotionally Affected After a Hysterectomy? The opinions expressed here are the views of the writer and do not necessarily reflect the views and opinions of News Medical. Is an RN currently licensed to practice in the State where he/she practices and is authorized to furnish the services of a CNS in accordance with State law. Advanced Practice Registered Nurse (APRN): A registered nurse, licensed by the state in which they practice who has completed an accredited graduate level educational program preparing her/him for one of the four recognized advanced practice roles, clinical nurse specialist, nurse practitioner, nurse midwife, or nurse anesthetist. Studies have demonstrated that NPs provide the same quality of care as physicians, yet they do not receive the same reimbursement. APRN Consensus Work Group, & National Council of State Boards of Nursing APRN Advisory Committee. The COVID- 19 pandemic serendipitously led to the removal of many restrictions on NP practice, a positive change that needs to become permanent. Patient satisfaction scores have also been comparable to those of physicians (Naylor & Kurtaman, 2010) (Table 1). There are two Medicare programs, Part A: covers hospitalization, hospice, skilled nursing facilities and some home care services and Part B, which covers physician services, outpatient hospital services, laboratory charges, medical equipment, and other home health services. Compensation should be mutually agreed upon by the employer and physician and included in a written contract. J Pediatr Health Care. What this means in practice is that many practice owners would rather see NPs bill incident to than under their own provider number. Healthcare has undergone many changes due to the COVID-19 pandemic. JWOCN, 2010, 14851. It was determined that there was no justification as to why CNMs should be reimbursed less than NPs or PAs (MedPAC, 2002). In this interview conducted at Pittcon 2023 in Philadelphia, Pennsylvania, we spoke to Ron Heeran, a speaker at the 2023 James L. Waters Symposium. Many were retrospective studies with limitations of potential bias and confounding issues. (2010). Administrators of Medicare, Medicaid, and commercial insurers may have policy level input into ordering decisions. University of Pennsylvania School of Nursing, Tags: covid-19, Education, Evolution, Medicare, MedPAC, Nursing, Pandemic, Primary Care, Research. MedPAC estimated that half of all primary care NPs are billing incident to. If that is eliminated, practices would lose 15% of reimbursement for those visits. Must be a registered professional nurse authorized by the state in which services are furnished to practice as a NP in accordance with state law and meet one of the following, Obtained Medicare billing privileges as a NP for the first time on or after January 1, 2003 and, Is certified as a NP by a recognized national certifying body that has established standards for NPs and. This fact sheet contains the best interpretation of the APRN reimbursement issues as of the date it was written. Current Medicare reimbursement for NPs comes from the Balanced Budget Act (1997)MedPAC meets frequently and issues two reports to Congress each year. Retrieved from: https://www.congress.gov/bill/101st-congress/house-bill/5835, U. S. Congress. Retrieved from: https://www.aafp.org/fpm/2015/0300/p15.html, Sullivan-Marx, E. M. (2008). NPs can bill incident to and receive 100% reimbursement. NPs should adopt the following practices to ensure their claims are reimbursed appropriately and promptly in order to stay up-to-date on each health plan's claims reimbursement requirements: NPs should know their contractual rights and responsibilities contained in provider contracts with health plans and third party payors. Therefore, it is difficult for payers and the public to recognize the productivity of the NPP (Medicare Payment Advisory Commission [MedPAC], 2019a) (See Table 1). Understanding the key concepts of APRN definition, Medicare billing regulations, other insurance's regulations, credentialing for privileges in the health care setting, inpatient versus outpatient billing issues, the use of CPT codes, and other topics as defined by the specific setting in which the APRN works is critical for success. Defense Attorney Provided. There are no separate CPT codes for these services. Why do NPs get reimbursed less than medical doctors for the same care? The 85% reimbursement policy is supported by the rationale that physicians have higher student loans, pay practice overhead cost, have higher malpractice premiums, and care for more complex patients (MedPAC, 2002). Therefore, NPPs cannot see new patients and bill incident to. Second, treatment for a specific problem must have already been initiated by the physician, so NPPs cannot see the patient for a new problem. However, the APRN should remember that insurers may regulate reimbursement in their own way. Medicare should increase the reimbursement rate of NPs to 100% of the physician payment rate. Incident to refers to a Medicare billing mechanism, allowing services furnished in an outpatient setting to be provided by auxiliary personnel and billed under the provider's NPI number.