Advocating reimbursement parity for nurse practitioners. Policy, Politics, & Nursing Practice, 9(2), 121-126. doi: 10.1177%2F1527154408318098, U. S. Congress. 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. Local Medicare contractors may specify the clinical circumstances under which a service is considered reasonable and necessary. ISSN: 1091-3734 American Nurses Association - 8515 Georgia Avenue - Suite 400 - Silver Spring, MD 20910, Sherry A. Greenberg, PhD, RN, GNP-BC, FGSA, FAANP, FAAN, Patricia Pittman, PhD, FAAN; Jeongyoung Park, PhD, Linda Millenbach, Ph.D, RN; Frances E. Crosby, Ed.D, RN; Jerome Niyirora, Ph.D, MS, RHIA; Kathleen Sellers, PhD, RN; Rhonda Maneval, DEd, RN; Jen Pettis, MS, RN, CNE, WCC; Noreen B. Brennan, PhD, RN-BC, NEA-BC; Mary Anne Gallagher, DNP, RN, Ped-BC; Nancy Michela, DAHS, MS, RN; Deborah Elliott, MBA, BSN, RN, Chad Rittle DNP, MPH, RN FAAOHN; Lora Walter, DNP, RNC-NIC, Garrett K. Chan, PhD, APRN, FAEN, FPCN, FCNS, FNAP, FAAN; Jana R. Bitton, MPA; Richard L. Allgeyer, PhD; Deborah Elliott, MBA, BSN, RN; Laura R. Hudson, MSN, RN; Patricia Moulton Burwell, PhD, Catherine A. Grano, MSN, RN, CSN-NJ; Eileen M. Gavin, MSN, FNP-BC, NCSN; Robin Cogan, MEd, RN, NCSN, Lakisha D. Flagg, DrPH, RN, PHNA-BC; Lisa A. Campbell, DNP, RN, PHNA-BC, FAAN, Francine H. Sheppard, PhD, RN, CNE, CDP; R. Turner Goins, PhD; Ratchneewan Ross, PhD, RN, FAAN; Kathleen Conte, PhD; Nicole Zonin, MSN, RN, Andrew R. Benson, DNP, MSN, CRNA, FAAN; Jessica S. Peters, DNP, MS, RN, ACNP-BC; Colleen Kennedy, DNP, CNM; Michelle Patch, PhD, MSN, APRN-CNS, ACNS-BC, Blima Marcus, DNP, RN, ANP-BC, OCN; Lindsey H. Danielson, MS, FNP-C; Tamar Y. Frenkel, BSN, RN, Post COVID-19 Reimbursement Parity for Nurse Practitioners. The American Nurses Credentialing Center. She specializes in teaching graduate nursing students about reimbursement and coding in the primary care setting. History of Nurse Practitioner (NP) Reimbursement from Centers for Medicare and Medicaid Services (CMS). NPs are doing much of the same work as their physician colleagues (Sullivan-Marx, 2008); therefore, they should receive the same reimbursement. The E&M service includes history taking, examination, medical decision-making (diagnosis and therapy) counseling, and coordination of care. 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. Workforce and reimbursement data were collected from a 2018 survey of Washington state advanced registered nurse practitioners (ARNPs). Retrieved from: https://www.govinfo.gov/content/pkg/STATUTE-91/pdf/STATUTE-91-Pg1485.pdf, U. S. Congress. NPI Number: Unique identification 10 digit numeric ID for covered health care providers. Dr. Greenberg is a nurse practitioner faculty consultant on the Institute for Healthcare Improvements Age-Friendly Health Systems initiative. The Journal for Nurse Practitioners, 10(9), A15-A16. (2021). Medicare program integrity manual chapter 15 Medicare enrollment #100-08, 2011. When services furnished to hospital inpatients and outpatients are billed directly, payment is unbundled and made to the APRN. 2. State practice environment. There are two Medicare programs, Part A: covers hospitalization, hospice, skilled nursing facilities and some home care services and Part B, which covers physician services, outpatient hospital services, laboratory charges, medical equipment, and other home health services. In the same 2002 session, MedPAC looked at the justification of the 85% rule. 10am - 8pm. UPDATED: NEW! These visits help you identify care gaps, increase revenue, and prepare your practice for value-based care. For a direct reimbursement, a practitioner must undergo an application process conducted by the payer. When the physician does not provide a face-to-face encounter, then report using the APRN's NPI.1416. This article offers a review of the issues, such as incident to billing; direct and indirect reimbursement; and quality of care. General billing requirements in Medicare claims processing manual section 30.3.12.1. Patient satisfaction scores for NPs were high, with millions of patients choosing NPs as their primary care provider. Diagnostic Responsibilities greater numbers of APRNs are able to work in a collaborative agreement rather than working for a physician in a complementary role. Diligence is required in selection of the appropriate code for services rendered since the code reported dictates the amount of reimbursement. An APRN must accept the payment from Medicare as full payment for the services provided. Medicare prospective payments made to hospitals are administered through Medicare Part A.2 Provider (both an APRN and a physician) services are reimbursed separately from the DRG system. Rural Health Clinic Services Act of 1977, Pub. In this interview conducted at Pittcon 2023 in Philadelphia, Pennsylvania, we spoke to Ron Heeran, a speaker at the 2023 James L. Waters Symposium. Thus, their recommendation was to continue with the 85% reimbursement rate (MedPAC, 2002). In June 2019, MedPAC again addressed payment policies for NPs and PAs. We use cookies to enhance your experience. Hospitalization rate with NP care was comparable to that of physicians. Direct Reimbursementwithout a physician on-site, NPPs were unable to receive any reimbursement for their services.In the 1970s, many physicians who practiced in rural areas began to retire and there was a lack of younger physicians to fill the vacancies. Add on codes describe additional intra-service work associated with the primary procedure and must be performed by the same provider. About MedPAC. This entire process may be lengthy, time consuming and monotonous but once you understand, you can surely do wonders. They should familiarize themselves with Medicare and Medicaid payment policies, and the state laws related to the private insurance practices. Employment relationships affect who has the right to bill for an APRN's services. (List separately in addition to code for primary procedure; CPT Codebook 2011.). (2010). Retrieved from: https://www.ruralhealthweb.org/getattachment/Advocate/Policy-Documents/RHCApril20143-(1).pdf.aspx?lang=en-US, Rapsilber, L. (2019). The processes and requirements of private insurance reimbursement for nurse practitioners vary depending on the payer, your specialty, and your state. For many APRNs this enrollment process is initiated by their employer.8. . Incident to billing practices are still in effect today. The 85% rule was instituted at a time when the work environment looked very different. When performing debridement of a single wound, report depth using the deepest level of tissue removed. (2020). APRN services can be reimbursed at the full fee schedule, if these services are provided by an APRN in the course of physician care, and billed as "incident to" a physician's services. Post Pandemic Billing PoliciesThe COVID-19 pandemic has demonstrated how removal of practice restrictions can increase the care NPs can deliver, while maintaining quality.The independent role of the NP continues to evolve. For example, preventive care, including cancer screenings, increased under the care of NPs. Charges for inpatient services are done using the Current Procedural Terminology (CPT) code system. The levels of E&M services are based on four types of examinations: problem focused, expanded problem focused, detailed, and comprehensive. Healthcare has undergone many changes due to the COVID-19 pandemic. University of Pennsylvania School of Nursing, Tags: covid-19, Education, Evolution, Medicare, MedPAC, Nursing, Pandemic, Primary Care, Research. 143. With the second method, Medicare, the nursing practitioner receives 80% of the fee that is set by the practice. 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. 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). This meant that all NPs could bill Medicare directly for services that they provided for patients, regardless of where those services were provided. The services provided must be under the provider's direct supervision; he/she must be in the area where care is delivered and be immediately available to provide assistance and supervision. CNMs received reimbursement of 65%, while NPs and PAs received reimbursement of 85% of the physician rate (Figure 1). This change could also increase feasibility for NPs to operate their own practices from a financial standpoint. 101-508, 104 Stat. 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. For encounters that do not meet incident to criteria, report using the APRN's NPI. Obtained Medicare billing privileges as a NP for the first time before January 1, 2003 and meets the certification requirements described above, or. 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. The COVID-19 pandemic has demonstrated how removal of practice restrictions can increase the care NPs can deliver, while maintaining quality. So, if a physician provides services to a patient Medicare deems worthy of a $100 reimbursement, the NP would be reimbursed $85 for providing the same care ( there are ways to get around this ). 10am - 10pm. Medicare Billing is done using either current procedural terminology (CPT) codes or evaluation and management (E&M) codes. Nurse lobbying groups compromised on the NP reimbursement rate of 85% of the physician fee because the location restriction for NP care was removed. Personal Injury Coverage. Montana's unemployment rate has fallen for four consecutive months, and the number of unemployed Montanans reached an all-time low in March. 9. Lilley C (2009). The total length of time of the encounter should be documented and the record should describe the counseling and/or activities to coordinate care. APRN services are paid using the PFS, as are "incident to" and diagnostic services furnished in a physician's or practitioner's office. Almost 90% of NPs are certified in primary care and 69% actually provide primary care. Advanced Practice Nurses must enroll in the Medicare program to be eligible to receive Medicare payment for covered services provided to Medicare beneficiaries. Retrieved from: https://www.nursing.upenn.edu/live/profiles/15283-quality-and-safety-of-nurse-practitioner-care-the, Chapman, S. A., Wides, C. D., & Spetz, J. The Balanced Budget Act of 1997 granted NPs the ability to directly bill Medicare for services that they perform. Kennerly S (2007). With the number of medical students going into primary care residencies on the decline, a shortage of 52,000 primary care physicians is expected by 2025 (Fodeman & Factor, 2015). 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. This inhibits the ability to track the number of patients assessed and managed by NPPs (Rapsilber, 2019). Repeated and frequent use of the code may lead to the development of a CPT for that service/procedure. There are three key components required when selecting the appropriate level of E&M service provided: history, examination, and medical decision making. Although there was no discussion at that time to increase the reimbursement from 85% to 100%, this could certainly be an opportunity for NPs to bring this issue back to the forefront. Compensation should be based on the amount of time, liability, and responsibility . More than 89% of NPs are certified in primary care, yet 69% actually practice in primary care (AANP, 2020).
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