8. Centers for Medicare & Medicaid Services (CMS). The current Medicare reimbursement policy for nurse practitioners allows them to directly bill Medicare for services that they perform, but they are reimbursed at only 85% of the physician rate. Why is the 85% reimbursement rate detrimental to NPs? As the number of NPs continued to rise, removing the location barrier was a great feat (Apold, 2011). Medical direction and appropriate supervision is provided as required by the law of the state in which the services are furnished (it is not required for the collaborating physician to be present when services are furnished or to independently evaluate patients). A NPI may be applied for at https://nppes.cms.hhs.gov. Nurses Service Organization (NSO). 2. The guidelines may include information such as settings of services (e.g., office, hospital, etc. with these terms and conditions. Currently, there is no uniform model of regulation of APRNs across the states. The COVID-19 pandemic has further supported the independent role of NPs.The COVID-19 pandemic has further supported the independent role of NPs. Hospitals planning to bill Medicaid, may query state Medicaid and commercial payers about their rules and policies.2. The Balanced Budget Act of 1997 granted NPs the ability to directly bill Medicare for services that they perform. For many APRNs this enrollment process is initiated by their employer.8. The numbers keep growing with over 28,700 recent graduates in 2018 (AANP, 2020). 5. Services or supplies that must be medically reasonable and necessary: Are proper and needed for the diagnosis or treatment of the beneficiary's medical condition. Service/procedure was increased or reduced. (1990). If not charted, the rationale for ordering diagnostic and other ancillary services should be easily inferred. When NPs bill incident to, data does not accurately reflect the types of patients that they treat, since the physician is credited for the patient visit, not the NP (Rapsilber, 2019). This contrasts with their 2002 decision to continue incident to billing. Appropriate health risks should be identified. However, without a physician on-site, NPPs were unable to receive any reimbursement for their services. Shared or split billing in the hospital inpatient/outpatient/emergency department setting. Balanced Budget Act of 1997, Pub. From 2010 2017, the number of NPs who billed Medicare increased by 151%. In June 2019, MedPAC again addressed payment policies for NPs and PAs. Defense Attorney Provided. Recognition of this productivity by both parties is crucial for NPPs to receive parity for equal services. The following definition of an APRN is Medicare's required qualifications.6 It appears that many other payer sources utilize Medicare's APRN qualifications. 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%. 3. Once the provider enrollment is complete, Proinp offers the consultation services . Alycia Bischof is a lecturer at the University of Pennsylvania School of Nursing. Your message has been successfully sent to your colleague. doi: 10.1097/MLR.0000000000000406, Medicare Payment Advisory Commission (MedPAC). MedPAC met in 2002 and determined that NP care is not equivalent to physician care. To provide the Advanced Practice Registered Nurse (APRN) with information to understand the opportunities and challenges in acquiring reimbursement for professional services. COVID-19 has led to even more states temporarily removing restrictions on NP practice as an effort to increase patient access to care (Zolot, 2020). During this same time, there was a surge of NPs and PAs. Is certified as a CNS by a recognized national certifying body that has established standards for CNSs. Reimbursement for nurse practitioner services Author C Buppert PMID: Abstract Whether a nurse practitioner (NP) is employed by a medical practice or is self-employed, the reimbursement policies of third-party payers will determine whether an NP continues to provide care on a long-term basis. Thus, it is suggested that each APRN examine the state regulations in the state or states where they will practice.5, The Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education5 has been endorsed by 41 nursing organizations, including the WOCN Society. Commercial Insurance - Health Care Reimbursement - Guides at Johns Hopkins University. Nursing Outlook, 67(6), 707712. Solutions to the primary care physician shortage. Credentialing and Privileging Provider credentialing and privileging is a practice in which documented recognition and verification is administered to a practicing professional. Services and procedures, with their identifying codes, are listed in numeric order with the exception of the Evaluation and Management (E&M) codes. Reimbursement Task Force and APRN Work Group, of the WOCN Society National Public Policy Committee, 2011. Centers for Medicare & Medicaid Services (CMS). The COVID-19 pandemic has demonstrated how removal of practice restrictions can increase the care NPs can deliver, while maintaining quality. (2002). A billing specialist or alternate source may review the documented services before the claim is submitted to the payer. This information is used by Medicare to provide reimbursement, collect statistics, and make future decisions upon reimbursement. There are more than 355,000 nurse practitioners (NPs) licensed in the U.S. 1. She is currently a DNP candidate at the University of Pennsylvania. The number of states granting full practice authority to NPs is growing. American Nurses Association (ANA) Website. High-protein diet counters adaptive thermogenesis in prediabetic individuals. may email you for journal alerts and information, but is committed Table 1. Below is a chart that lists the elements of each level of medical decision making. Even more states have loosened practice restrictions due to COVID-19. 13. 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. 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). We consider MedPAC and reimbursement policy, post COVID-19 policy solutions, and action steps to move forward to seek reimbursement parity. In June 2002, they voted unanimously to increase CNM reimbursement from 65% to 85%. They should familiarize themselves with Medicare and Medicaid payment policies, and the state laws related to the private insurance practices. 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. We use cookies to enhance your experience. Conversely, the number of NPs is on the rise. 2, Manuscript 3. RVUs consider not only clinician work for the service provided, but also includes overhead office expenses and professional liability insurance expenses. 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. For example, rounding is a physician service but not billable. Retrieved from: http://www.medpac.gov/docs/default-source/reports/jun02_NonPhysPay.pdf?sfvrsn=0, Medicare Payment Advisory Commission (MedPAC). Billing is per encounter, not per specific service. In an article in The Online Journal of Issues in Nursing, Alycia Bischof, MSN, APRN, PNP-BC, Senior Lecturer at the University of Pennsylvania School of Nursing (Penn Nursing), argues that given the increased role of NPs (particularly during the pandemic) and their proven ability to provide care comparable to physicians, Congress should allow Medicare to increase the NP reimbursement rate to 100% of the physician pay rate. As practitioners of any level are named in lawsuits, insurers will increase premiums to cover the outlay resulting from those suits. Examples include, office or outpatient setting; hospital inpatient; emergency department; and nursing facility. 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. Alycia Bischof, MSN, APRN, PNP-BCEmail: abischof@nursing.upenn.edu, Sherry A. Greenberg, PhD, RN, GNP-BC, FGSA, FAANP, FAANEmail: sherry.greenberg@shu.edu. Nurse-managed health centers and retail clinics that are run and managed by NPs are expanding.Barnes, Aiken and Villaruel (2016) reviewed over 40 years of studies that all support the quality and safety of NP care. Impact of COVID-19 Pandemic on Nurses: Where is the Financial Safety Net? Evaluation and Management Services Part B. Now is the time for NPs to receive full reimbursement from Medicare. 1995 Documentation Guidelines for Evaluation & Management Services, 1999. To get around this rule, PAs are able to choose "bill incident to," which consists of billing . Dr. Greenberg earned Bachelor, Master, and PhD degrees in nursing from the University of Pennsylvania School of Nursing and was a Jonas Nurse Leaders Scholar. 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. (See Table 1: Consensus Model: Definition of Advanced Practice Registered Nurse.). There are no separate CPT codes for these services. This fact sheet will provide an overview of reimbursement and issues related to billing for advanced practice nurse services. The decrease in reimbursement results in financial instability and decreased employment opportunities, in addition to decreased recognition of the value of NP visits and care (Chapman et al., 2010). E&M services are arranged into different settings depending on where the service is provided. First, the patient must have already established care with the physician. 18. In order for the APRN role to survive in many settings, a revenue stream may need to be developed. CPT procedural codes can be billed by any qualified provider. National Rural Health Association Policy Brief. The E&M service includes history taking, examination, medical decision-making (diagnosis and therapy) counseling, and coordination of care. NPs provide quality, cost effective care (Barnes et al., 2016; Kippenbrock et al., 2019; Naylor & Kurtzman, 2010). 26, No. Unfortunately, CMS did not change the reimbursement rate. As impressive as these numbers are, the actual numbers are higher because many NPs are still billing under incident to, and these visits are not reflected in the data. On occasion, there are services or procedures that are not found in the CPT codebook. These studies must further explore the effect that NPs have on healthcare today. 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). 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. What level of coverage does the APRN have with the policy (per incident, per lifetime, etc.)? Therefore, NPPs have a choice: bill under their own provider number and receive 85% reimbursement and accurately track NP-specific practice trends and payments or, satisfy the incident to rules and receive 100% reimbursement (Chapman, Wides, & Spetz, 2010). The Journal for Nurse Practitioners, 7(5), 356. doi: 10.1016/j.nurpra.2011.03.013, Barnes, H., Aiken, L. H., & Villarruel, A. M. (2016). ), 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. Reimbursement by private insurance companies is separate from the Medicare process and may require a credentialing process. 3. Buppert C. Billing for Nurse Practitioner Services-update 2007: Guidelines for NP's, physicians, employers and insurers, Medscape nurses, 2007. With the second method, Medicare, the nursing practitioner receives 80% of the fee that is set by the practice. Dr. Sherry Greenberg is an Associate Professor at Seton Hall University College of Nursing and a Courtesy-Appointed Associate Professor at New York University Rory Meyers College of Nursing.

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