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|Description / paper instructions
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various coding and billing
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numbers for nurse
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ctice_Registered.4.aspxn order for the APRN role to survive in many settings, a revenue stream may need to be developed. There are increased opportunities for billing of APRN services and it is important that APRNs understand the issues involved in capturing third party reimbursement. There are many legal and financial issues that need to be appreciated by the APRN as they relate to reimbursement. Reimbursement is a complex structure that includes regulatory factors both at the state and federal level. For example, APRNs may bill Medicare under the physician payment system only if the APRN has the legal authority under state law to perform the service to be billed.1 Clarification on the issue of legal authority will be covered under the definition of an advanced practice nurse, since states license APRNs, there is variation between states on the definition of an APRN. Rules for billing are complicated, scattered throughout Federal and State law, and vary from payer to payer.2 While this fact sheet will cover Medicare billing regulations, many insurers will follow Medicare guidelines. However, the APRN should remember that insurers may regulate reimbursement in their own way.The history of APRN reimbursement is important to understand as it provides context to what follows. In 1990, direct APRN reimbursement by Medicare was available only in rural areas and skilled nursing facilities.3 In 1997, Medicare expanded reimbursement for Clinical Nurse Specialists (CNS) and Nurse Practitioners (NP; as well as nurse anesthetists and nurse midwives, however these roles will not be covered in this fact sheet) to all geographical and clinical settings allowing direct Medicare reimbursement to the APRN, but at 85% of the physician rate.1 This success was won because of the powerful political action of the American Nurses Association, utilizing outcome data to show how CNS’ and NPs make a difference in cost and quality, and the political action partnerships established with specialty organizations and grassroots actions of local nurses.
This fact sheet will provide an overview of reimbursement and issues related to billing for advanced practice nurse services. The regulatory environment is complex and APRNs should understand the regulations to maximize reimbursement opportunities and investigate billing possibilities. It is important to note that in addition to federal billing guidelines, each state has licensing authority for APRNs and this licensing authority can be different depending upon the state in which the APRN practices. Each APRN will need to review their state licensing regulations as well as confer with their billing experts on the interpretation of the billing regulations. This fact sheet contains the best interpretation of the APRN reimbursement issues as of the date it was written. It is hoped that this fact sheet will provide a starting place for the APRN to become acquainted with billing issues and opportunities, but is not meant to be an authoritative paper on all issues related to billing.
Definition: Advanced Practice Registered Nurses
The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education5 has been endorsed by 41 nursing organizations, including the WOCN Society. 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. This important document should be accessed to see the recommendations that reflect a need and desire to increase the clarity and uniformity of APRN regulation with hope that in the future this document will be used as a reference for regulatory issues. (See Table 1: Consensus Model: Definition of Advanced Practice Registered Nurse.)
Medicare’s Definition and Qualifications of an APRN
The following definition of an APRN is Medicare’s required qualifications.6 It appears that many other payer sources utilize Medicare’s APRN qualifications.
Clinical Nurse Specialist:
Services or supplies that must be medically reasonable and necessary:
The APRN may bill the Medicare program directly for services using his/her national provider identifier (NPI) or under an employer’s or contractor’s NPI. 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). 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. A NPI may be applied for at https://nppes.cms.hhs.gov. 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. “Incident to” billing is beyond the scope of this fact sheet; for information on incident to billing, refer to the WOCN Society fact sheet entitled: “Understanding Medicare Part B ‘Incident to’ Billing.” (In press, 2011.)
Payment is made only on an assignment basis, which means that payment will be the Medicare allowed amount as payment in full and the APRN may not bill or collect from the beneficiary any amount other than unmet copayments, deductibles, and/or coinsurance. Services are paid at 85% of the Medicare Physician Fee schedule amount. When services furnished to hospital inpatients and outpatients are billed directly, payment is unbundled and made to the APRN.
Advanced Practice Nurses must enroll in the Medicare program to be eligible to receive Medicare payment for covered services provided to Medicare beneficiaries. Form CMS-8551 is used for physicians and non-physician practitioners (i.e., APRNs) to initiate the Medicare enrollment process. If the APRN is part of a clinic or group practice, Form CMS 855B is used to initiate the enrollment process. There is an Internet based Provider Enrollment, Chain and Ownership System (PECOS) that can be used. For many APRNs this enrollment process is initiated by their employer.8
The APRN must understand and meet the state licensing requirements in the state where his/her delivery of services will take place, must meet the Medicare requirements to bill Medicare, and have a NPI. Reimbursement by private insurance companies is separate from the Medicare process and may require a credentialing process.
Credentialing and Privileging
APRN Inpatient Reimbursement
Medicare inpatient hospital billing principles are identified as:
The service must be a physician service.
Provider services are reimbursed separately from other services provided in hospitals. Medicare payments for provider services are reimbursed through Medicare Part B. Provider services are defined by Federal regulations as diagnosis, therapy, surgery, consultation, care plan oversight; and home, office and institutional visits. Charges for inpatient services are done using the Current Procedural Terminology (CPT) code system. The Evaluation and Management (E&M) service is the most common service provided by an APRN in the hospital. The E&M service includes history taking, examination, medical decision-making (diagnosis and therapy) counseling, and coordination of care. CPT procedural codes can be billed by any qualified provider.
The hospital can bill for the APRN’s services under the physician/provider payment system if the salary and benefits of the APRN are not reimbursed under the hospital’s cost report. The salary of the APRN must be unbundled from the hospital’s cost report. The hospital cannot bill Medicare if the APRN’s salary is being reimbursed under Part A of Medicare.1,2
There are some services provided by the APRN that are physician services but are not billable. For example, “rounding” is a physician service but not billable. Initiating transfers and writing transfer orders are physician services but are not billable. Writing orders to change an intravenous solution is not a billable service. There are no separate CPT codes for these services. These services are part of the package of treatment and communication services bundled together and identified by the CPT codes for E&M.
When an APRN evaluates and manages a patient’s illness or injury through history taking, examination and medical decision making, the work is billable because all of the required elements of the service have been performed. If an APRN changes a dose of digoxin based on the laboratory results from earlier in the day, it is considered a provider service (medical decision-making). However, if the documentation is lacking the history or examination, the service is not billable because it is just one part of a package of services or E&M bundled together for reimbursement purposes.2
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. However, if the APRN simply dictates the discharge summary and/or orders without performing the other functions, the APRN’s services are not billable.
Medicare and other payers will reimburse providers for items or services that are “reasonable and necessary for a diagnosis or injury or to improve the functioning of a malformed body member.”9 Both the medical record and billing claim must describe or indicate why the service was necessary. Administrators of Medicare, Medicaid, and commercial insurers may have policy level input into ordering decisions. Local Medicare contractors may specify the clinical circumstances under which a service is considered reasonable and necessary. Policies may vary from region to region.
Shared or split billing in the hospital inpatient/outpatient/emergency department setting. 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. However, if there was no face-to-face encounter between the patient and the physician (for instance, the physician only reviewed the chart), then the service may only be billed under the APRN’s NPI entered on the claim. 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.
If a hospital or medical practice bills for an APRN service when another provider has already billed that same service one of the bills may be denied. Therefore, it is necessary for the APRN and physician to coordinate their visits. If an APRN performs sections of the E&M and a provider of the same specialty then repeats that exam or adds to the APRN service, there is a choice to be made. Either the service can be billed under the APRN and receive 85% of the physician’s scheduled rate or the service can be billed under the physician’s number and receive 100% of the physician’s rate.10 If the APRN and the physician are employed by different groups and both groups submit bills, the second bill to arrive at the payer’s office will be denied.
If the APRN is performing pre-operative examinations and post-operative E&M for surgical patients, this is included in the global surgical package for major surgery. The global surgical package is a fixed fee to cover all treatment and services related to the surgical procedure including pre-operative visits after the decision is made to operate beginning with the day before the surgery, intraoperative services, and complications following surgery. The time frame depends upon the surgical procedure and is 90 days, 10 days or 0 days; with major surgery, the global period is 90 days; and minor surgery varies between 0-10 days.9
Current Procedural Terminology Codes
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. CPT codes are developed, maintained, and copyrighted by the American Medical Association (AMA). The five-digit number assigned to each code refers to a specific service or procedure that a provider may supply to a patient including medical, surgical, and diagnostic services. The purpose of the CPT code is to provide a uniform language that accurately describes services rendered. The uniform language serves as an effective means for reliable nationwide communication between medical practitioners, patients, and third parties.11 Third parties (e.g., insurers) use the CPT codes to determine the amount of reimbursement to be paid to the practitioner.
In the CPT codebook, sold only by AMA or AMA designees, codes are listed in six sections or code sets. These code sets are then sub-sectioned by anatomic, procedural, condition, or descriptor subheadings. Services and procedures, with their identifying codes, are listed in numeric order with the exception of the Evaluation and Management (E&M) codes. E&M codes, which are numbered 99201-99249, are listed at the beginning of the code sets as these codes are the most frequently used by medical practitioners for reporting services.
At the beginning of each code set, specific guidelines identify items that are necessary for appropriately interpreting and reporting the services and procedures within that set. The guidelines may include information such as settings of services (e.g., office, hospital, etc.), special reports that are required as part of the service, supplies, and materials provided and/or face-to-face time as a basis for selection of a specific code. Diligence is required in selection of the appropriate code for services rendered since the code reported dictates the amount of reimbursement.
On occasion, there are services or procedures that are not found in the CPT codebook. 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. Therefore, the designated unlisted service/procedure codes are monitored by the AMA for recurrent use. Repeated and frequent use of the code may lead to the development of a CPT for that service/procedure.
Some procedural codes are commonly carried out in addition to the primary procedure performed. Add on codes describe additional intra-service work associated with the primary procedure and must be performed by the same provider. A descriptor of an add-on code would contain phrases like “each additional” or “list separately in addition to primary procedure code.”
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. The modifiers allow medical practitioners to effectively respond to payment policy requirements established by other entities. The modifiers have specific numeric identifiers (listed in the appendices of the codebooks) and cover one of the following alterations in the service/procedure:
Service/procedure had both a professional and technical component.
Section/code set: Surgery
Wound debridement (codes: 11042-11047) is reported by the depth of tissue that is removed and by the surface area of the wound. These services may be reported for injuries, infections, wounds, and chronic ulcers. When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths. For example, when a bone is debrided from a 4 sq cm heel ulcer and from a 10 sq cm ischial ulcer, report the work with a single code, 11044. 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. If all four wounds were debrided on the same day, use modifier 59 with 11042, 11045, and 11044.11
Section/code set: Medicine
90901: Biofeedback training by any modality.
90911: Biofeedback training, perineal muscles, anorectal or urethral sphincter, including Electromylogram and/or manometry.
(For testing of rectal sensation, tone, and compliance, use code 91120.)
(For incontinence treatment by pulsing magnetic neuromodulation, use code 53899.)11
Evaluation and Management Services Codes
Health care payers may require rational documentation to assure that a service was consistent with the patient’s insurance coverage and to validate the place of service, the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided. It is also necessary to document that the services provided have been accurately reported.
Documentation of each patient’s encounter should include seven key components:
The chief complaint or reason for the visit and relevant history;
E&M services are arranged into different settings depending on where the service is provided. Examples include, office or outpatient setting; hospital inpatient; emergency department; and nursing facility. Patients are identified as either new or established depending on previous encounters with the provider or the provider’s group.
The code sets used to bill for E&M services are organized into various levels and categories. The more complex the visit, the higher the level of code that the provider may bill within the appropriate category. The volume of charting does not dictate the level of billing. The services must meet the definition of the code.
There are three key components required when selecting the appropriate level of E&M service provided: history, examination, and medical decision making. Visits that consist primarily for counseling and/or coordination of care are an exception to the rule.
The elements required for each type of history are listed in Table 2.
There are two versions of the documentation guidelines – the 1995 and the 1997 versions. Either version may be used (but not both) by the provider for a patient encounter. The most substantial difference between the two versions is in the examination section. Any provider, regardless of specialty, may perform both types of examinations. It is important to keep in mind with both the 1995 and 1997 documentation guidelines, that noting an abnormal or unexpected finding in an examination requires further description, whereas a brief statement or notation indicating a negative or normal finding is sufficient for documentation related to unaffected areas or asymptomatic system(s).12,13
Medical decision-making refers to the complexity of making a diagnosis and/or selecting management choice. This is determined by considering the following factors: number of possible diagnoses or management options, the amount and/or complexity of medical records, diagnostic tests and/or other information that must be obtained, reviewed, and investigated, the risk of significant complications, morbidity, and/or mortality as well as co-morbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the potential management options.
Below is a chart that lists the elements of each level of medical decision making. Note that to qualify for a given type of medical decision-making, two of the three elements must either be met or exceeded.
When counseling and/or coordination of care takes more than 50% of the provider/patient and/or family encounter (face-to-face time in the office or other outpatient setting, floor/unit time in the hospital or nursing home), the time is considered the key or controlling factor to qualify for a particular level of E&M service. 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 Level I and Level II CPT books available from the AMA lists average time guidelines for a variety of E&M services. These times include work performed before, during and after the encounter.
Split/Shared Services are an encounter where a Physician and a NPP each personally perform a portion of the E&M visit. There are rules for reporting these services.
For office/clinic setting encounters with established patients that meet the “incident to” requirements, report using the physician’s National Provider Identifier (NPI). For encounters that do not meet “incident to” criteria, report using the APRN’s NPI. In the hospital inpatient, outpatient and Emergency Department (ED) setting encounters shared between a physician and an APRN from the same group practice, when the physician provides any face-to-face portion of the encounter, report using either provider’s NPI. When the physician does not provide a face-to-face encounter, then report using the APRN’s NPI.14–16
Liability (Malpractice) Insurance
In addition, an employer’s policy does not protect the APRN’s license to practice. Conflict of interest can arise between the APRN and the employer itself. For instance, if being named jointly with an employer in a lawsuit, the employer can argue that facility’s procedures were not followed to the letter. Maintaining that argument can devastate the practitioner’s career, even if the case is dismissed from court or the practitioner is acquitted of malpractice. 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). An investigation will be triggered and the practitioner will be required to hire his/her own defense attorney. If the Board decides to file disciplinary action against the practitioner, his/her career as an APRN could be tainted or ruined.
APRNs should question their actual or potential employer about the policy carried to cover them as employees. The following are issues to investigate:
Is the APRN protected individually under the policy (specifically named as an insured party)?
Diagnostic Responsibilities – greater numbers of APRNs are able to work in a collaborative agreement rather than working for a physician in a complementary role.
There are multiple sources of APRN liability insurance available. As the APRN determines his/her practice site preference, he/she will need to investigate levels of minimal as well as maximal coverage for their practice, which is generally based on risk association for the type practice (some areas of practice have higher litigious rates and therefore higher premiums). While negotiating a contract, liability (malpractice) insurance coverage is a key issue to be addressed. APRNs can request the employer to provide individual liability insurance as a part of their benefit package as long as it truly meets the APRNs coverage needs.
“Incident to” Billing
NPI NUMBER National Plan and Provider Enumeration System
EHR Electronic health records (EHRs), with their adoption incentivized as part of the American Recovery and Reinvestment Act of 2009, are now a ubiquitous part of the health care landscape. Although these systems promised to improve the quality of patient care, increase efficiency, and reduce costs, health care providers are finding that current EHRs instead require time-consuming data entry, can interfere with patient interactions, and cause medical errors. Nurse practitioners should implement practical tips and best practices for navigating and successfully using EHRs, as well as risk management strategies to ensure better patient care and avoid malpractice litigation or licensing issues.