What Is A Registered Nurse Who Has Advanced Training In Anesthetic Administration Known As?

Purpose:

To provide the Advanced Practice Registered Nurse (APRN) with information to empathize the opportunities and challenges in acquiring reimbursement for professional services.

Originated By:

Reimbursement Chore Force and APRN Work Group, of the WOCN Society National Public Policy Committee, 2011

Date Completed:

September two, 2011

Background

In 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 empathise the bug involved in capturing 3rd party reimbursement. In that location are many legal and financial issues that need to be appreciated by the APRN every bit they relate to reimbursement. Reimbursement is a complex structure that includes regulatory factors both at the state and federal level. For example, APRNs may nib Medicare under the physician payment system only if the APRN has the legal dominance nether country law to perform the service to exist billed.¹ Clarification on the consequence of legal say-so will be covered under the definition of an avant-garde do 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 police, and vary from payer to payer.² While this fact sheet will comprehend 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 just in rural areas and skilled nursing facilities.³ In 1997, Medicare expanded reimbursement for Clinical Nurse Specialists (CNS) and Nurse Practitioners (NP; too equally nurse anesthetists and nurse midwives, however these roles volition non exist covered in this fact sheet) to all geographical and clinical settings assuasive direct Medicare reimbursement to the APRN, just at 85% of the doc rate.¹ This success was won because of the powerful political action of the American Nurses Association, utilizing outcome information to show how CNS' and NPs make a difference in price and quality, and the political action partnerships established with specialty organizations and grassroots actions of local nurses.

This fact canvass will provide an overview of reimbursement and issues related to billing for avant-garde practice nurse services. The regulatory environment is circuitous and APRNs should understand the regulations to maximize reimbursement opportunities and investigate billing possibilities. It is important to note that in improver to federal billing guidelines, each state has licensing authority for APRNs and this licensing authority tin be different depending upon the land 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 bug as of the date it was written. It is hoped that this fact canvass will provide a starting place for the APRN to become acquainted with billing issues and opportunities, but is not meant to exist an administrative paper on all issues related to billing.

Definition: Avant-garde Practise Registered Nurses

The American Nurses Clan (ANA) has advocated that all advance practice nurses have one title of Advance Practice Registered Nurse (APRN). According to the ANA, the APRN holds a high level of expertise in the assessment, diagnosis and handling of complex responses of individuals, families or communities to bodily or potential health problems, prevention of disease and injury, maintenance of health and provision of comfort. The APRN has a master'south or doctoral degree concentrating in a specific surface area of advanced nursing practice, had supervised practice during graduate education, and has ongoing clinical experiences. APRNs include clinical nurse specialists, nurse practitioners, nurse anesthetists, and nurse midwives.⁴ While education, accreditation, and certification are necessary components of an overall approach to preparing an APRN for practice; the licensing boards governed by state regulations and statutes-are the final arbiters of who is recognized to exercise within a given land. Currently, there is no uniform model of regulation of APRNs across united states. Each land independently determines the APRN legal scope of practice, the roles that are recognized, the criteria for entry-into advanced exercise, and the certification examinations accepted for entry-level competence assessment. Thus, it is suggested that each APRN examine the country regulations in the state or states where they will practice.⁵

The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Instruction⁵ has been endorsed by 41 nursing organizations, including the WOCN Society. The APRN Consensus Model defines avant-garde 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 certificate should be accessed to meet the recommendations that reverberate a demand and want to increase the clarity and uniformity of APRN regulation with hope that in the future this certificate will be used as a reference for regulatory bug. (See Table 1: Consensus Model: Definition of Advanced Practice Registered Nurse.)

T1-4 — TABLE ane:
Consensus Model: Definition of Avant-garde Practice Registered Nurse

An APRN may exist prepared every bit a clinical nurse specialist, a nurse practitioner, a certified nurse midwife, or a certified registered nurse anesthetist. This paper volition utilize the term advanced exercise nurse to merely include the clinical nurse specialist and the nurse practitioner. The term provider will include the APRN and the dr..

Medicare's Definition and Qualifications of an APRN

The following definition of an APRN is Medicare's required qualifications.^{half dozen} Information technology appears that many other payer sources apply Medicare's APRN qualifications.

Clinical Nurse Specialist:

Is an RN currently licensed to practise in the Country where he/she practices and is authorized to replenish the services of a CNS in accordance with State law.
Has a Principal'due south caste or Md of Nursing Practice in a divers clinical area of nursing from an accredited educational institution and
Is certified as a CNS by a recognized national certifying trunk that has established standards for CNSs.

Nurse Practitioner:

Must be a registered professional person nurse authorized by the state in which services are furnished to exercise every bit a NP in accord with land law and run across one of the following
Obtained Medicare billing privileges as a NP for the first time on or afterward January 1, 2003 and
Is certified every bit a NP by a recognized national certifying torso that has established standards for NPs and
Has a Primary's degree in nursing or a Doctor of Nursing Do caste.
Obtained Medicare billing privileges as a NP for the first time before January ane, 2003 and meets the certification requirements described in a higher place, or
Obtained Medicare billing as a NP for the starting time time earlier January 1, 2001.

The national certifying bodies that Medicare recognizes are:⁷

The American Nurses Credentialing Center,
The National Certification Corporation for Obstetrics, Gynecologic, and Neonatal Nursing Specialties,
The American Academy of Nurse Practitioners,
The Pediatric Nursing Certification Lath (formerly National Certification Board of Pediatric Nurse Practitioners and Nurses),
The Oncology Nursing Certification Corporation,
The Critical Care Certification Corporation now called AACN Certification Corporation, and
National Lath of Certification of Hospice and Palliative Nurses.

Medicare Coverage Criteria for Medicare Services Furnished by Advanced Practice Registered Nurse

The post-obit are the Medicare required APRN coverage criteria:⁶

Services or supplies that must exist medically reasonable and necessary:

Are proper and needed for the diagnosis or treatment of the beneficiary'due south medical status,
Are furnished for the diagnosis, direct care and handling of the casher's medical condition,
Encounter the standard of practiced medical practice, and
Are not mainly for the convenience of the beneficiary, provider, or supplier.

The following must exist met:

Services are performed in collaboration with a md. Collaboration occurs when the APRN works with one or more than physicians to deliver health care services within the scope of their professional expertise. Medical direction and appropriate supervision is provided equally required past the law of the land in which the services are furnished (it is non required for the collaborating physician to be present when services are furnished or to independently evaluate patients).
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
He or she is legally authorized and qualified to replenish the services in the state where they are performed.

Additionally, a nurse practitioner may be selected as a hospice beneficiary's attending medico, but he/she cannot certify or recertify a concluding illness with a prognosis of six months or less.

The APRN may pecker the Medicare program directly for services using his/her national provider identifier (NPI) or under an employer's or contractor'due south NPI. A NPI is a unique 10-digit identification number issued to wellness 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 practical for at https://nppes.cms.hhs.gov. If billing is washed via "incident to" services, these claims must be submitted under the supervising physician's NPI and identified on provider file by specialty lawmaking 50 for nurse practitioners and 89 for clinical nurse specialists. "Incident to" billing is beyond the scope of this fact sail; for data on incident to billing, refer to the WOCN Society fact canvass entitled: "Understanding Medicare Office B 'Incident to' Billing." (In printing, 2011.)

Payment is made merely on an assignment basis, which means that payment will be the Medicare allowed corporeality every bit payment in total and the APRN may not beak or collect from the beneficiary any amount other than unmet copayments, deductibles, and/or coinsurance. Services are paid at 85% of the Medicare Md Fee schedule amount. When services furnished to infirmary inpatients and outpatients are billed straight, payment is unbundled and made to the APRN.

Advanced Do Nurses must enroll in the Medicare program to be eligible to receive Medicare payment for covered services provided to Medicare beneficiaries. Class CMS-8551 is used for physicians and non-physician practitioners (i.e., APRNs) to initiate the Medicare enrollment process. If the APRN is role of a dispensary or group practice, Class CMS 855B is used to initiate the enrollment procedure. At that place is an Internet based Provider Enrollment, Chain and Ownership System (PECOS) that tin 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 land where his/her delivery of services will have place, must meet the Medicare requirements to bill Medicare, and have a NPI. Reimbursement past private insurance companies is divide from the Medicare process and may require a credentialing process.

Credentialing and Privileging

Provider credentialing and privileging is a do in which documented recognition and verification is administered to a practicing professional. The credentialing organisation is used by various organizations and agencies to ensure that their health care practitioners see all the necessary requirements and are appropriately qualified. This process ofttimes occurs before the provider is hired. It is used to ostend the provider's license, educational activity, training, controlling, and overall quality. The process varies between facilities but may include completion of an awarding for credentialing and privileging, primary source verification of credentials, review lath and approving. The application may include a curriculum vitae, copy of current licensure, verification of graduation from approved program, copy of certification, letters of recommendation, malpractice history, and other documents as identified by the place of employment. Wellness care facilities set their own guidelines regarding how ofttimes a provider is re-credentialed to maintain their status.

APRN Inpatient Reimbursement

The following principles on inpatient APRN reimbursement are based on Medicare rules. Not all payers follow Medicare rules and this includes Medicaid. Hospitals planning to pecker Medicaid, may query state Medicaid and commercial payers about their rules and policies.²

Medicare inpatient hospital billing principles are identified every bit:

The service must be a physician service.
The service cannot exist just one part of a bundled service.
The service must be within the APRN's scope of practice under country constabulary. State laws specify the physician services that APRNs are authorized to perform and each state'south definition is slightly different.
The service must be medically necessary.
The APRN must come across the payer's credentialing requirements.
Documentation of the service must conform to the payer's requirements for the procedure code billed.
By and large, the APRN's services should exist billed under the APRN's provider number. Nevertheless, at that place are exceptions to this statement.
It is permissible to bill visits "shared" with physicians, under certain conditions.
Medicare will pay only 1 charge per twenty-four hour period, per patient, per specialty, for Evaluation and Management billing.
A hospital may not pecker Medicare Office B for an APRN'southward services if the infirmary receives any reimbursement for the APRN'due south bacon under the hospital toll written report.
The services of residents, nursing students, medical students, physician assistant students and APRN students cannot be billed under an APRN'south provider number.
Employment relationships touch on who has the right to bill for an APRN'south services.
An APRN must accept the payment from Medicare as full payment for the services provided.

State laws authorize APRNs to perform nursing services and some dr. services. Nursing services are reimbursed through prospective payments or payments based on direct Diagnosis Related Groups (DRG). If an APRN performs a complicated dressing change or pouching procedure, which is a nursing service, information technology is not a billable service. That service is covered by the DRG payment or the per diem payment to the hospital. Medicare prospective payments fabricated to hospitals are administered through Medicare Part A.² Provider (both an APRN and a doc) services are reimbursed separately from the DRG organization.

Provider services are reimbursed separately from other services provided in hospitals. Medicare payments for provider services are reimbursed through Medicare Function B. Provider services are divers by Federal regulations as diagnosis, therapy, surgery, consultation, care plan oversight; and domicile, office and institutional visits. Charges for inpatient services are washed using the Current Procedural Terminology (CPT) code system. The Evaluation and Direction (E&M) service is the almost common service provided by an APRN in the hospital. The Due east&1000 service includes history taking, examination, medical controlling (diagnosis and therapy) counseling, and coordination of care. CPT procedural codes can be billed by whatsoever 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 nether the hospital's toll study. The salary of the APRN must exist unbundled from the infirmary's price report. The hospital cannot neb Medicare if the APRN's salary is beingness reimbursed under Function A of Medicare.¹ ^, ²

In that location are some services provided by the APRN that are physician services only are not billable. For case, "rounding" is a medico service but not billable. Initiating transfers and writing transfer orders are md services but are not billable. Writing orders to change an intravenous solution is non a billable service. There are no separate CPT codes for these services. These services are part of the package of handling and communication services arranged together and identified by the CPT codes for East&M.

When an APRN evaluates and manages a patient'south affliction or injury through history taking, examination and medical decision making, the work is billable because all of the required elements of the service take been performed. If an APRN changes a dose of digoxin based on the laboratory results from earlier in the twenty-four hours, 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 information technology is just 1 part of a package of services or Due east&One thousand bundled together for reimbursement purposes.²

Hospital discharges are billable if the service includes performing the final examination of the patient, discussion of the infirmary stay, educational activity for continuing care to all caregivers, prescriptions and referral forms and grooming of belch records. However, if the APRN simply dictates the discharge summary and/or orders without performing the other functions, the APRN'southward 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 fellow 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 up billing in the infirmary inpatient/outpatient/emergency department setting. When an E&M is shared between a doc and APRN from the same group do and the doctor provides any face to face portion of the E&K meet with the patient, the service may be billed under the physician'south or the APRN's NPI number. However, if there was no face-to-face encounter between the patient and the physician (for instance, the md simply reviewed the chart), then the service may just exist billed under the APRN's NPI entered on the merits. An case 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 practise bills for an APRN service when another provider has already billed that same service one of the bills may be denied. Therefore, information technology 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 aforementioned specialty then repeats that exam or adds to the APRN service, in that location is a selection to exist fabricated. 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 dr.'south number and receive 100% of the physician's rate.^ten If the APRN and the dr. are employed by different groups and both groups submit bills, the second beak to get in at the payer's part will be denied.

If the APRN is performing pre-operative examinations and mail-operative Eastward&M for surgical patients, this is included in the global surgical parcel for major surgery. The global surgical package is a fixed fee to encompass all treatment and services related to the surgical process including pre-operative visits afterwards the decision is made to operate get-go with the day earlier 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 menses is xc days; and minor surgery varies between 0-10 days.^ix

Current Procedural Terminology Codes

Medicare Billing is done using either current procedural terminology (CPT) codes or evaluation and direction (E&Grand) codes. This section will comprehend electric current process terminology, evaluation and management codes will follow.

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 5-digit number assigned to each code refers to a specific service or process that a provider may supply to a patient including medical, surgical, and diagnostic services. The purpose of the CPT code is to provide a compatible language that accurately describes services rendered. The compatible linguistic communication serves as an effective ways for reliable nationwide advice betwixt medical practitioners, patients, and third parties.^xi Third parties (east.chiliad., insurers) utilize the CPT codes to determine the amount of reimbursement to be paid to the practitioner.

In the CPT codebook, sold simply by AMA or AMA designees, codes are listed in six sections or lawmaking 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 guild with the exception of the Evaluation and Management (E&M) codes. Eastward&M codes, which are numbered 99201-99249, are listed at the beginning of the code sets as these codes are the nearly ofttimes used by medical practitioners for reporting services.

At the commencement of each code set up, specific guidelines place items that are necessary for appropriately interpreting and reporting the services and procedures within that fix. 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 every bit a footing for option of a specific lawmaking. Diligence is required in selection of the appropriate code for services rendered since the code reported dictates the corporeality of reimbursement.

On occasion, at that place are services or procedures that are not found in the CPT codebook. For that reason, the AMA has designated several specific lawmaking 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 utilize. Repeated and frequent use of the lawmaking may lead to the development of a CPT for that service/procedure.

Some procedural codes are ordinarily carried out in addition to the primary procedure performed. Add on codes draw additional intra-service piece of work associated with the principal procedure and must be performed by the same provider. A descriptor of an add-on code would comprise phrases like "each additional" or "listing separately in add-on to main procedure code."

Modifiers tin can besides be added to CPT codes as a means of reporting or indicating that a service/procedure rendered has been altered past some specific circumstance just that information technology did not modify the definition or lawmaking. 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 ane of the post-obit alterations in the service/procedure:

Service/process had both a professional and technical component.
Service/procedure was performed by more ane provider and/or in more than than 1 location.
Service/process was increased or reduced.
Simply part of a service was performed.
An adjunctive service was performed.
A bilateral procedure was performed.
Service/procedure was provided more than one time.
Unusual events occurred.¹¹

APRNs seeking specific codes related to services and/or procedures provided in the WOC nursing arena, will detect no specific codes for ostomy intendance. E&M codes will have to suffice at this time. In that location are codes related to wounds and continence services. The post-obit two examples are provided as a guide in using the CPT codebook.¹¹

Department/lawmaking set: Surgery

Sub-section: Anatomic

Sub-heading: Integumentary

Debridement:

Wound debridement (codes: 11042-11047) is reported by the depth of tissue that is removed and past the expanse 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 os is debrided from a 4 sq cm heel ulcer and from a 10 sq cm ischial ulcer, report the work with a single lawmaking, 11044. When subcutaneous tissue is debrided from a 16 sq cm dehisced abdominal wound and a 10 sq cm thigh wound, report the piece of work with 11042 for the commencement xx sq cm and 11045 for the second 6 sq cm. If all four wounds were debrided on the same day, utilize modifier 59 with 11042, 11045, and 11044.¹¹

Debridement Codes:

11042: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed): first 20 sq cm or less.11045: Each additional 20 sq cm, or office thereof. (Listing separately in add-on to code for chief procedure; CPT Codebook 2011.)

Section/code set: Medicine

Sub-section: Biofeedback

Codes:

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 handling by pulsing magnetic neuromodulation, use code 53899.)¹¹

Evaluation and Direction Services Codes

The CPT codes which describe doc-patient encounters are often referred to as Evaluation and Management Codes. Evaluation and Direction Services refer to visits and consultations furnished by providers. A provider'south Medicare benefit allows him/her to neb for E&M services and the services must exist provided within the scope of their practice in the state in which the provider practices.

Health care payers may require rational documentation to assure that a service was consistent with the patient'due south insurance coverage and to validate the place of service, the medical necessity and ceremoniousness of the diagnostic and/or therapeutic services provided. It is as well necessary to document that the services provided have been accurately reported.

Documentation of each patient's see should include seven key components:

The chief complaint or reason for the visit and relevant history;
Physical test findings and prior diagnostic test results;
Medical decision making;
Counseling;
Coordination of care;
Nature of presenting trouble; and
Fourth dimension spent with the patient.

Included should also be the cess, clinical impression or diagnosis, medical programme of care and engagement, and legible identity of the observer. Appropriate health risks should exist identified. If not charted, the rationale for ordering diagnostic and other ancillary services should exist easily inferred. By and present diagnoses should exist easily accessible to the treating and consulting providers. The patient's progress, response to and changes in treatment, along with the revision of diagnosis should be documented. The diagnosis and handling codes reported on the health insurance claim course or billing statement should be supported past the documentation on the medical record. It is the responsibleness of the provider to ensure that the submitted merits is correct and reflects the services provided. A billing specialist or alternate source may review the documented services before the claim is submitted to the payer.

E&Thou services are bundled into different settings depending on where the service is provided. Examples include, office or outpatient setting; hospital inpatient; emergency section; and nursing facility. Patients are identified as either new or established depending on previous encounters with the provider or the provider's grouping.

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 beak inside 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 primal components required when selecting the appropriate level of East&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.

The levels of E&M services are based on 4 types of examinations: problem focused, expanded problem focused, detailed, and comprehensive. The type and extent of the examination performed is based upon clinical judgment, the patient's history, and the nature of the presenting problem.

There are two versions of the documentation guidelines – the 1995 and the 1997 versions. Either version may exist used (but not both) by the provider for a patient run into. The virtually substantial difference between the two versions is in the exam department. Whatever provider, regardless of specialty, may perform both types of examinations. Information technology 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 cursory statement or annotation indicating a negative or normal finding is sufficient for documentation related to unaffected areas or asymptomatic system(s).¹² ^, ¹³

Medical controlling refers to the complication of making a diagnosis and/or selecting management selection. This is adamant by considering the following factors: number of possible diagnoses or management options, the amount and/or complication of medical records, diagnostic tests and/or other information that must be obtained, reviewed, and investigated, the run a risk of significant complications, morbidity, and/or mortality every bit well as co-morbidities associated with the patient'southward presenting problem(s), the diagnostic procedure(s), and/or the potential direction options.

Below is a chart that lists the elements of each level of medical determination making. Note that to authorize for a given type of medical determination-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 function or other outpatient setting, floor/unit time in the hospital or nursing home), the time is considered the cardinal or controlling factor to authorize for a item level of East&M service. The total length of fourth dimension of the run across should be documented and the record should describe the counseling and/or activities to coordinate intendance. The Level I and Level Ii CPT books available from the AMA lists average fourth dimension guidelines for a variety of E&1000 services. These times include piece of work performed before, during and after the encounter.

Separate/Shared Services are an encounter where a Doctor and a NPP each personally perform a portion of the E&Thou visit. There are rules for reporting these services.

For office/dispensary setting encounters with established patients that meet the "incident to" requirements, written report using the doctor's National Provider Identifier (NPI). For encounters that do non meet "incident to" criteria, study using the APRN's NPI. In the infirmary inpatient, outpatient and Emergency Department (ED) setting encounters shared between a physician and an APRN from the same grouping practice, when the dr. provides any face-to-face portion of the encounter, report using either provider'south NPI. When the dr. does not provide a face-to-face run into, and so written report using the APRN's NPI.¹⁴ ^– ¹⁶

Liability (Malpractice) Insurance

APRNs (equally with all other practitioners who provide medical services/procedures) are working in a lawsuit driven environment. There are numerous factors that contribute to the take chances for being named in a lawsuit, among them are patient load, voluminous paperwork associated with care provided, and staffing shortages. One negative outcome, whether existent or perceived past the patient or caregiver, can easily result in a lawsuit. Professional person liability (malpractice) insurance tin protect the practitioner's family unit, savings, personal belongings, domicile, and whatsoever other assets of value.

Institutions, such as medical centers and/or hospitals, long-term care facilities and/or home wellness agencies, carry "blanket" liability on employees but the primary purpose of this insurance is to protect the employing agency. If a medical lawsuit is filed naming an individual practitioner along with the facility, the practitioner's interests in the defence force may differ greatly from those of the facility/employer, who must protect its own reputation and finances.

In add-on, an employer's policy does not protect the APRN'south 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 tin can argue that facility'south procedures were non followed to the letter. Maintaining that statement 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 correct to file a complaint against the practitioner to his/her licensing body (i.e., the state's Board of Nursing). An investigation volition be triggered and the practitioner volition exist required to hire his/her own defence chaser. If the Lath decides to file disciplinary activeness confronting the practitioner, his/her career as an APRN could be tainted or ruined.

APRNs should question their bodily or potential employer most the policy carried to cover them as employees. The following are problems to investigate:

Is the APRN protected individually under the policy (specifically named equally an insured political party)?
Does the insurance include License Protection to help with defense of the APRN in an administrative or disciplinary state of affairs?
If the APRN leaves the employment of the facility/agency, does the policy embrace for an incident that occurred while still employed (is the employer'due south policy "Occurrence")?
Does the APRN have private limits of liability?
What level of coverage does the APRN have with the policy (per incident, per lifetime, etc.)?
Enquire to run into the policy (if the APRN has a personal attorney, can he/she review the policy)?
Does the policy cover 24 hours/twenty-four hours?
What is the employer's insurance company'due south stability rating?¹⁷

APRNs are held legally accountable to their telescopic of practice and are therefore facing greater malpractice exposure than ever before, specially in two key areas:

Diagnostic Responsibilities – greater numbers of APRNs are able to piece of work in a collaborative understanding rather than working for a doctor in a complementary part.
Prescriptive Dominance – APRNs can prescribe under their own signature in many states.

To appointment, APRN liability (malpractice) insurance premiums are less expensive than their counterparts (physicians and physician assistants). According to Nurses Service Organization,¹⁷ this is subject to change as the number and severity of claims against APRNs is on the rise. As practitioners of whatsoever level are named in lawsuits, insurers volition increase premiums to cover the outlay resulting from those suits.

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 too as maximal coverage for their practise, which is generally based on risk association for the type practice (some areas of do have higher litigious rates and therefore college premiums). While negotiating a contract, liability (malpractice) insurance coverage is a central effect to be addressed. APRNs can request the employer to provide individual liability insurance as a part of their do good bundle as long as it truly meets the APRNs coverage needs.

"Incident to" Billing

"Incident to" refers to a Medicare billing mechanism, allowing services furnished in an outpatient setting to exist provided by auxiliary personnel and billed under the provider's NPI number. The provider can be a doc, nurse practitioner, clinical nurse specialist, physician's assistant, nurse midwife, and clinical psychologist. The services provided must exist under the provider'due south direct supervision; he/she must be in the area where care is delivered and exist immediately available to provide help and supervision. The provider must initiate a class of handling and the services done by the auxiliary staff include follow up intendance, and profitable in the plan of care. In some outpatient settings, there may be an opportunity for a non-provider (i.e., not-APRN) to provide care and obtain reimbursement every bit "incident to" the provider's services. The provider can exist a dr. or an advanced practise nurse so there may be opportunities for an APRN to direct care of patients with wound, ostomy and continence intendance issues and for not-APRNs to provide the care. A potential downside to "incident to" billing, when done by the APRN, is that the APRN's services are folded into the medico'due south data and this makes it difficult to document the exact services rendered by the APRN or the revenue generated past them.¹⁸ It is beyond the scope of this fact sail to cover "incident to" in detail, the reader is referred to the WOCN Society fact sheet entitled: "Understanding Medicare Function B 'Incident to' Billing." (In press, 2011.)

Summary

Agreement and in some cases pursuing reimbursement for advanced practice nursing services may be central for survival in today's health care environs. To be prepared to participate in today'south wellness care manufacture, APRNs need to exist competent clinicians but also need to be well versed in the business side of providing intendance. Understanding the key concepts of APRN definition, Medicare billing regulations, other insurance'south regulations, credentialing for privileges in the wellness care setting, inpatient versus outpatient billing issues, the apply of CPT codes, and other topics as defined by the specific setting in which the APRN works is critical for success. This fact sheet was written to provide the reader with an overview and is not meant to be an exhaustive authorization on this subject. The information provided may change, depending on the electric current reimbursement environment and it is suggested that the reader seek out the references and additional reading resource listed below.

References

2. Buppert C. Billing for Nurse Practitioner Services-update 2007: Guidelines for NP's, physicians, employers and insurers, Medscape nurses, 2007. http://www.medscape.org/viewarticle/562664_print. Accssed July 26, 2010.

Cited Hither

iii. Frakes Evans T. An Overview of Medicare Reimbursement Regulations for Advanced Practise Nurses, 2006. http://world wide web.medscape.com/viewarticle/531035

Cited Here

4. American Nurses Association (ANA) Website. Retrieved from http://nursingworld.org.

Cited Here

5. APRN Consensus Work Group, & National Council of Land Boards of Nursing APRN Informational Commission. Consensus model for APRN regulation: Licensure, accreditation, certification & education, 2008. https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf.

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six. Medicare Learning Network (MLN). Medicare information for advanced practice nurses and physician assistants, 2010. http://www.cms.gov/MLNProducts/downloads/Medicare_Information_for_APNs_and_PAs_Booklet_ICN901623.pdf. Accessed March 20, 2011.

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7. Centers for Medicare & Medicaid Services (CMS). Medicare program integrity manual chapter 15 – Medicare enrollment #100-08, 2011. http://world wide web.cms.gov/manuals/downloads/pim83c15.pdf. Accessed February 25, 2011.

Cited Here

8. Centers for Medicare & Medicaid Services (CMS). Medicare provider-supplier enrollment > overview, 2011. https://world wide web.cms.gov/MedicareProviderSupEnroll/

Cited Here

9. 42 Code of Federal Regulations (CFR), section 410.ii. 2005. http://edocket.access.gpo.gov/cfr_2005/octqtr/pdf/42cfr410.21.pdf. Accessed March viii, 2011.

Cited Here

10. Centers for Medicare & Medicaid Services (CMS). General billing requirements in Medicare claims processing manual section 30.3.12.one. https://world wide web.cms.gov/manuals/downloads/clm104c01.pdf. Accessed March 8, 2011.

Cited Hither

11. CPT Codebook 2011, AMA.

Cited Here

12. Medicaid Learning Network (MLN). 1995 Documentation Guidelines for Evaluation & Management Services, 1999. http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf.

Cited Here

xiii. Medicaid Learning Network (MLN). (northward.d.). 1997 Documentation Guidelines for Evaluation and Management Services. http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf.

Cited Hither

14. Centers for Medicare & Medicaid Services (CMS). (2010). Evaluation and Management Services Role B. http://www.trailblazerhealth.com/Publications/Preparation%20Manual/EvaluationandManagementServices.pdf.

Cited Here

16. Medicare Learning Network (MLN). Documentation Guidelines for Evaluation and Management (East/M). 2011. http://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp.

Cited Hither

17. Nurses Service Organization (NSO). Frequently asked questions about professional liability insurance of NPs, 2011. http://www.nso.com.

Cited Here

xviii. Reimbursement for Nurse Practitioner Services Position Argument. J Pediatr Wellness Intendance. 2004;18:27A–28A.

Cited Here

Boosted Reading

Coalition for Nurses in Advanced Practice (n.d.). Reimbursement: Full general data. Retrieved July 25, 2010 from http://www.cnaptexas.org/displaycommon.cfm?an=one&subarticlenbr=17

Kennerly S (2007). The impending reimbursement revolution: How to ready for futurity APN reimbursement. Nursing Economics, 2007, 25:2, 81–84.

Lilley C (2009). APN reimbursement, April 15, 2009 Presentation by Christa Liley-Kennedy Grouping Enterprises, Inc. personal communication.

Medicare Alerts. (2010). Ohio Association of Advanced Practice Nurses. Retrieved June 3, 2010, from http://www.oaapn.org/medicare_alerts.php

Partin B (2009). Advocacy in practice; advocate modify 1 nurse at a fourth dimension. The Nurse Practitioner: The American Periodical of Primary Health Intendance, : 2009 34:1,9.

Phillips South. 22nd annual legislative update regulatory and legislative successes for APNs. The Nurse Practitioner: The America Journal of Chief Health Care, : 35:11, 24–47.

Plager Yard. A., Conger G. M (2007). Avant-garde practice nursing; constraints to role fulfillment. The Internet Journal of Advanced Practice Nursing, 2007, nine:1–8. Retrieved March 31, 2011, from http://world wide web.ispub.com/journal/the_internet_journal_of_advanced_nursing_practice/volume_9_number_1_3/commodity/advanced_practice_nursing_constraints_to_role_fulfillment.html

Schaumm Thousand (2009). Does your hospital-endemic outpatient wound care section have the required "direct supervision?" Advances in Skin and Wound Care, one:6, 256–254.

Sullivan Due east. G. (2008). Lessons learned from avant-garde practise nursing payment. Policy, Politics and Nursing Practice. 9:2, 2008, 121–26.

Vargo D (2010). Direct supervision requirements and incident to services a primer for the WOC nurse. JWOCN, 2010, 148–51.

Glossary

Glossary

Advanced Practice Registered Nurse (APRN): A registered nurse, licensed by the state in which they practice who has completed an accredited graduate level educational plan preparing her/him for one of the four recognized advanced practice roles, clinical nurse specialist, nurse practitioner, nurse midwife, or nurse anesthetist. The APRN has passed a national certification examination that measures APRN, function and population focused competencies and who maintains connected competence as evidenced by recertification in the role and population through the national certification programs. (Adapted from the LACE consensus model.)^five

Credentialing: A method to document recognition and verification of a provider's qualifications to practice in a health intendance setting.

Current Procedural Terminology (CPT): Systematic list and coding of procedures/services performed by providers that serve equally the ground for health care billing.

Due east&M Services: Evaluation and management services are CPT codes which describe doc-patient encounters are often referred to equally Evaluation and Direction Codes. Evaluation and Direction Services refer to visits and consultations furnished by providers.

Hospital Toll Study: All Medicare certified institutional providers are required to submit an annual cost report to the Fiscal Intermediary. The report contains information such a facility characteristics, utilization data, toll, and charge by cost middle and financial statement data. This data is used by Medicare to provide reimbursement, collect statistics, and make hereafter decisions upon reimbursement.

International Nomenclature of Disease, Diagnosis, and Procedural Codes (ICD-10): Is a replacement for ICD-9-CM diagnosis and procedure codes. It volition be used for services provided on or after October 1, 2013, for all Health Insurance Portability and Accountability Act covered entities.

Medicare: Federal health insurance program for the elderly and disabled. There are two Medicare programs, Role A: covers hospitalization, hospice, skilled nursing facilities and some habitation care services and Role B, which covers doc services, outpatient hospital services, laboratory charges, medical equipment, and other domicile wellness services. The Medicare programs are administered by the Center for Medicare and Medicaid Services (CMS). Medicare Office A is managed by a contracting agency called an intermediary agency; Medicare Part B is managed by a contracting agency called a carrier.

Medicaid: State administered programme for low-income families and children, significant women, the aged, blind and disabled and long-term intendance.

NPI Number: Unique identification 10 digit numeric ID for covered health care providers. Data: world wide web.cms.gov/nationalprovidentstand/