Reimbursement parity will make it easier for NPs to meet the growing need for primary care providers.MedPAC has already supported an increase in reimbursement for CNMs in 2002 and as recently as 2019 reconsidered how Medicare reimburses NPs. In order for the APRN role to survive in many settings, a revenue stream may need to be developed. The Evaluation and Management (E&M) service is the most common service provided by an APRN in the hospital. The volume of charting does not dictate the level of billing. The current Medicare reimbursement policy for nurse practitioners (NPs) allows NPs to directly bill Medicare for services that they perform, but they are reimbursed at only 85% of the physician rate. Portable Coverage - Take it with you. 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. Why would anyone running a practice want to lose 15% of revenue for every patient that the NP sees? 95-210. National Rural Health Association Policy Brief. Are not mainly for the convenience of the beneficiary, provider, or supplier. It is the responsibility of the provider to ensure that the submitted claim is correct and reflects the services provided. Medicare will reimburse NP care at 100% if the visit is billed as incident to rather than under the NPs own NPI number. Direct billing to nurse practitioners allows for 85% of the reimbursement rate that a physician would receive. APRNs should question their actual or potential employer about the policy carried to cover them as employees. In their June 2019 report, MedPAC acknowledged that care once provided by physicians is shifting toward NPs and PAs (MedPAC, 2019a). From 2010 2017, the number of NPs who billed Medicare increased by 151%. CPT codes are developed, maintained, and copyrighted by the American Medical Association (AMA). The current Medicare reimbursement policy for nurse practitioners (NPs) should be changed to allow 100% reimbursement for care rendered by NPs. The chief complaint or reason for the visit and relevant history; Physical examination findings and prior diagnostic test results; Is the APRN protected individually under the policy (specifically named as an insured party)? 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.). The American Journal of Medicine, 128(8), 800-801. doi: 10.1016/j.amjmed.2015.02.023, Hansen-Turton, T., Bailey, D. N., Torres, N., & Ritter, A. Retrieved July 25, 2010 from. This entire process may be lengthy, time consuming and monotonous but once you understand, you can surely do wonders. 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. PDF How Medicare Pays APRNs - Fee for Service and Medicare Advantage For a direct reimbursement, a practitioner must undergo an application process conducted by the payer. Medicare information for advanced practice nurses and physician assistants, 2010. Incident to billing practices are still in effect today. M-level Service Desk. Medical Payments - up to $25,000 per person, up to $100,000 annual aggregate. Business and personal vehicles must comply with California's auto liability insurance requirements: $15,000 in bodily injury liability or death liability per person. Therefore, the designated unlisted service/procedure codes are monitored by the AMA for recurrent use. Almost 90% of NPs are certified in primary care and 69% actually provide primary care. 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. Increasing the reimbursement rate to 100% will support NPs in all these settings and most appropriately increase the healthcare workforce in the provision of primary care. Establish Insurance Reimbursement Contracts. A growing number of states are granting full practice authority to nurse practitioners. ), 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. ), (For incontinence treatment by pulsing magnetic neuromodulation, use code 53899.)11. 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). Guides: Health Care Reimbursement: Commercial Insurance First, the patient must have already established care with the physician. RVUs consider not only clinician work for the service provided, but also includes overhead office expenses and professional liability insurance expenses. Almost 90% of NPs are certified in primary care and 69% actually provide primary care. NP Fact Sheet - American Association of Nurse Practitioners Retrieved from: https://www.aanp.org/advocacy/advocacy-resource/position-statements/position-statements, American Association of Nurse Practitioners (AANP). This becomes even more important if Congress chooses to accept MedPACs recommendation and eliminate incident to billing. A new Penn Nursing article argues that payment parity is essential. The CPT codes which describe physician-patient encounters are often referred to as Evaluation and Management Codes. With the second method, Medicare, the nursing practitioner receives 80% of the fee that is set by the practice. Reimbursement for Nurse Practitioner Services | Nurse Key The following are issues to investigate: APRNs are held legally accountable to their scope of practice and are therefore facing greater malpractice exposure than ever before, especially in two key areas: To date, APRN liability (malpractice) insurance premiums are less expensive than their counterparts (physicians and physician assistants). Within Parts A and of Medicare are benefit categories that allow Medicare to make payment for specific services. The COVID-19 pandemic has demonstrated how removal of practice restrictions can increase the care NPs can deliver, while maintaining quality. The information provided may change, depending on the current reimbursement environment and it is suggested that the reader seek out the references and additional reading resources listed below. 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. While negotiating a contract, liability (malpractice) insurance coverage is a key issue to be addressed. The local Medicare will give the nursing practitioner a unique identification number (UPIN) for his or her bills. Two of the current members are nurses (MedPAC, 2021). To provide the Advanced Practice Registered Nurse (APRN) with information to understand the opportunities and challenges in acquiring reimbursement for professional services. The COVID- 19 pandemic serendipitously led to the removal of many restrictions on NP practice, a positive change that needs to become permanent. Centers for Medicare & Medicaid Services (CMS). How does incident to billing affect NP practice? Medicaid: State administered program for low-income families and children, pregnant women, the aged, blind and disabled and long-term care. You may be trying to access this site from a secured browser on the server. Consensus model for APRN regulation: Licensure, accreditation, certification & education, 2008. Credentialing and Privileging Provider credentialing and privileging is a practice in which documented recognition and verification is administered to a practicing professional. Medicaid Learning Network (MLN). Report to the Congress: Medicare and the Healthcare Delivery System. According to Nurses Service Organization,17 this is subject to change as the number and severity of claims against APRNs is on the rise. Colorado enacted Chapter Number 77 "Nurse Practitioner Workers' Compensation" (HB 19-1105), granting the ability of advanced practice nurses with prescriptive authority to receive Level 1 accreditation for the purposes of receiving 100% reimbursement under the "Workers Compensation Act of Colorado." This provision was effective August 2, 2019. American Association of Nurse Practitioners (AANP). Medicare should increase the reimbursement rate of NPs to 100% of the physician payment rate. Medicare will pay only one charge per day, per patient, per specialty, for Evaluation and Management billing. The history of APRN reimbursement is important to understand as it provides context to what follows. Example: A physician sees a patient in their office and bills Medicare for that office visit. 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. Omnibus Budget Reconciliation Act of 1990, Pub. Retrieved from: https://www.congress.gov/bill/105th-congress/house-bill/2015, U. S. Congress. 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. Evaluation and Management Services refer to visits and consultations furnished by providers. Number of nurse practitioners hits new record high. The Nurse Practitioner, 44(2), 15-17. doi: 10.1097/01.npr.0000552680.76769.e5, Shay, D. F. (2015). High-protein diet counters adaptive thermogenesis in prediabetic individuals. Each state independently determines the APRN legal scope of practice, the roles that are recognized, the criteria for entry-into advanced practice, and the certification examinations accepted for entry-level competence assessment. Advocating for Washington state ARNP payment parity : The Nurse - LWW 2. (1977). Medicare is a defined benefit category program. Journal of Wound Ostomy & Continence Nursing39(2S):S7-S16, March/April 2012. Figure. 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 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. Reimbursement of Advanced Practice Registered Nurse Services - LWW APRNs should receive appropriate reimbursement from Medicaid. Split/Shared Services are an encounter where a Physician and a NPP each personally perform a portion of the E&M visit. Frakes Evans T. An Overview of Medicare Reimbursement Regulations for Advanced Practice Nurses, 2006. 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 number of Evaluation & Management (E/M) visits by NPs increased from 11 million to 31 million, while the number of visits billed by physicians decreased by 16%. Provider services are defined by Federal regulations as diagnosis, therapy, surgery, consultation, care plan oversight; and home, office and institutional visits. American Journal of Nursing, 110(9), 23-26. doi: 10.1097/01.NAJ.0000388257.41804.41, Kippenbrock, T., Emory, J., Lee, P., Odell, E., Buron, B., & Morrison, B. CPT procedural codes can be billed by any qualified provider. Lessons learned from advanced practice nursing payment. Retrieved from: http://www.medpac.gov/docs/default-source/reports/jun19_medpac_reporttocongress_sec.pdf?sfvrsn=0, Medicare Payment Advisory Commission (MedPAC). Congress has not acted on this recommendation (MedPAC, 2019a). The Act requires NPs and CNSs to be paid 85% of the amount paid to a physician. 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. 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. NPs now run rural health clinics, nurse managed centers and retail clinics (Hansen-Turton et al., 2010). By continuing to browse this site you agree to our use of cookies. Generally, the APRN's services should be billed under the APRN's provider number. For more information, please refer to our Privacy Policy. 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. Information: www.cms.gov/nationalprovidentstand/. 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). Evaluating the association between Mediterranean Diet adherence and type 2 diabetes using nutritional biomarkers. One negative outcome, whether real or perceived by the patient or caregiver, can easily result in a lawsuit. Highmark Health, in an emailed statement, defended the change, noting that the new reimbursement rate for advanced practice registered nurses is "commensurate with required training, experience . (n.d.). Interestingly, they also reconsidered incident to billing and decided to continue reimbursing NPPs at 100% if they submitted the bill as incident to (MedPAC, 2002). Multiple studies have demonstrated that NPs provide quality care comparable with, if not better than physicians (Kippenbrock et al., 2019). Their role in healthcare has also evolved. This change could also increase feasibility for NPs to operate their own practices from a financial standpoint. 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. Potentially preventable hospitalizations in Medicare patients with diabetes: A comparison of primary care provided by nurse practitioners versus physicians. This paper will utilize the term advanced practice nurse to only include the clinical nurse specialist and the nurse practitioner. 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. Reimbursement issues in advanced practice nursing: an overview Increasing reimbursement for NPs from 85% to 100% would support more robust primary care. This meant that all NPs could bill Medicare directly for services that they provided for patients, regardless of where those services were provided. Retrieved from http://www.medpac.gov/-about-medpac-, Naylor, M. D., & Kurtzman, E. T. (2010). (n.d.). International Classification of Disease, Diagnosis, and Procedural Codes (ICD-10): Is a replacement for ICD-9-CM diagnosis and procedure codes. A potential downside to incident to billing, when done by the APRN, is that the APRN's services are folded into the physician's information and this makes it difficult to document the exact services rendered by the APRN or the revenue generated by them.18 It is beyond the scope of this fact sheet to cover incident to in detail, the reader is referred to the WOCN Society fact sheet entitled: Understanding Medicare Part B Incident to Billing. (In press, 2011.). Once the provider enrollment is complete, Proinp offers the consultation services . Nursing services are reimbursed through prospective payments or payments based on direct Diagnosis Related Groups (DRG). The service must be within the APRN's scope of practice under state law. History of Nurse Practitioner (NP) Reimbursement from Centers for Medicare and Medicaid Services (CMS). Incident to billing practices are still in effect today. Residents in these communities were often older adults, minorities, and low-income populations traditionally with significant healthcare needs. 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. Services are paid at 85% of the Medicare Physician Fee schedule amount. Medicare program integrity manual chapter 15 Medicare enrollment #100-08, 2011. Dr. Greenberg has worked as a certified gerontological nurse practitioner in acute, long-term care, and outpatient primary care practices and has taught at undergraduate and graduate nursing levels. There are increased opportunities for billing of APRN services and it is important that APRNs understand the issues involved in capturing third party reimbursement. 18. Conflict of interest can arise between the APRN and the employer itself. Over the past decade, the number of NPs has dramatically increased, from 120,000 in 2007 (American Association of Nurse Practitioners [AANP], 2018) to 290,000 in 2019 (AANP, 2020). Patient satisfaction scores for NPs were high, with millions of patients choosing NPs as their primary care provider. These services are part of the package of treatment and communication services bundled together and identified by the CPT codes for E&M. Documentation of each patient's encounter should include seven key components: Included should also be the assessment, clinical impression or diagnosis, medical plan of care and date, and legible identity of the observer. 3. Payment regulations for advanced practice nurses: implications for Either version may be used (but not both) by the provider for a patient encounter. The following are the Medicare required APRN coverage criteria:6. Nurse practitioner Medicare reimbursement rates should be bumped up from 85% of the physician pay rate to the . Wolters Kluwer Health 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. with these terms and conditions. The National Certification Corporation for Obstetrics, Gynecologic, and Neonatal Nursing Specialties. Any provider, regardless of specialty, may perform both types of examinations. This implies that APNs should know the federal and state laws, rules, and regulations that clearly define their scope of practice and prescriptive authority. The role of the NP has expanded in the last two decades. In the same 2002 session, MedPAC looked at the justification of the 85% rule. on this website is designed to support, not to replace the relationship Initially, care delivered by NPs was billed under the physicians name as incident to payment. Vargo D (2010). The APRN has a master's or doctoral degree concentrating in a specific area of advanced nursing practice, had supervised practice during graduate education, and has ongoing clinical experiences.
