Nursing- Advanced Primary Care Of Family Practicum 2 (Due 24 Hours)

1) Minimum 4 full pages  (Follow the 3 x 3 rule: minimum three paragraphs per part)

Parts 1 and 2 are the same question, however, you must answer both questions with references and different writing always addressing them objectively, that is as if you were two different people. Similar responses in wording or references will not be accepted.

Parts 3 and 4 are the same question, however, you must answer both questions with references and different writing always addressing them objectively, that is as if you were two different people. Similar responses in wording or references will not be accepted.

             Part 1: Minimum 1 page

             Part 2: minimum 1 page

             Part 3: Minimum 1 page  

             Part 4: minimum 1 page

Submit 1 document per part

2)¨******APA norms

          All paragraphs must be narrative and cited in the text- each paragraphs

          Bulleted responses are not accepted

          Don’t write in the first person 

          Don’t copy and pase the questions.

          Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph

Submit 1 document per part

3)****************************** It will be verified by Turnitin (Identify the percentage of exact match of writing with any other resource on the internet and academic sources, including universities and data banks) 

********************************It will be verified by SafeAssign (Identify the percentage of similarity of writing with any other resource on the internet and academic sources, including universities and data banks)

4) Minimum 3 references per part not older than 5 years

5) Identify your answer with the numbers, according to the question. Start your answer on the same line, not the next

Example:

Q 1. Nursing is XXXXX

Q 2. Health is XXXX

6) You must name the files according to the part you are answering: 

Example:

Part 1.doc 

Part 2.do

__________________________________________________________________________________

Parts 1 and 2 are the same question, however, you must answer both questions with references and different writing always addressing them objectively, that is as if you were two different people. Similar responses in wording or references will not be accepted.

Parts 3 and 4 are the same question, however, you must answer both questions with references and different writing always addressing them objectively, that is as if you were two different people. Similar responses in wording or references will not be accepted.

Part 1: Advanced Primary Care of Family Practicum – Nursing

Read the following article (Check file):

https://journals.lww.co m/jwocnonline/Fulltext/ 2012/03001/Reimburse ment_of_Advanced_Pra ctice_Registered.4.aspx

1. Prepare examples of various coding and billing issues that you have experienced in the clinical setting (Peds and Women’s Health).

2. Provide a brief description about the NPI numbers for nurse practitioners.

Part 2: Advanced Primary Care of Family Practicum – Nursing

Read the following article (Check file):

https://journals.lww.co m/jwocnonline/Fulltext/ 2012/03001/Reimburse ment_of_Advanced_Pra ctice_Registered.4.aspx

1. Prepare examples of various coding and billing issues that you have experienced in the clinical setting (Peds and Women’s Health).

2. Provide a brief description about the NPI numbers for nurse practitioners.

Part 3: Advanced Primary Care of Family Practicum -Nursing

Reflect back over the past 14 weeks and describe how your achievements in this course have prepared you to meet the MSN program outcomes. 

Approach the following topics as Nurse: (Write in the first person)

1. Clinical experience

2. Make and design soap notes

3. Diagnosis diseases in women, children, and men

4. Physical exam (primary consult)

Read the following article:

https://www.mdedge.co m/clinicianreviews/artic le/152683/practicemanagement/whatareyou-worth-basicsbusiness-healthcare

Part 4: Advanced Primary Care of Family Practicum-Nursing

Reflect back over the past 14 weeks and describe how your achievements in this course have prepared you to meet the MSN program outcomes. 

Approach the following topics as Nurse: (Write in the first person)

1. Clinical experience

2. Make and design soap notes

3. Diagnosis diseases in women, children, and men

4. Physical exam (primary consult)

Read the following article:

https://www.mdedge.co m/clinicianreviews/artic le/152683/practicemanagement/whatareyou-worth-basicsbusiness-healthcare

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Copyright © 2012 by the Wound, Ostomy and Continence Nurses Society J WOCN ■ March/April 2012 S7

Copyright © 2012 Wound, Ostomy and Continence Nurses Society. Unauthorized reproduction of this article is prohibited.

J Wound Ostomy Continence Nurs. 2012;39(2S):S7-S16. Published by Lippincott Williams & Wilkins

Reimbursement of Advanced Practice Registered Nurse Services A Fact Sheet

Purpose: To provide the Advanced Practice Registered Nurse (APRN) with information to understand the opportunities and chal- lenges in acquiring reimbursement for professional services.

Originated By: Reimbursement Task Force and APRN Work Group, of the WOCN Society National Public Policy Committee, 2011

Date Completed: September 2, 2011

■ Background

In order for the APRN role to survive in many settings, a revenue stream may need to be developed. There are in- creased opportunities for billing of APRN services and it is important that APRNs understand the issues involved in capturing third party reimbursement. There are many legal and fi nancial issues that need to be appreciated by the APRN as they relate to reimbursement. Reimbursement is a com- plex structure that includes regulatory factors both at the state and federal level. For example, APRNs may bill Medicare under the physician payment system only if the APRN has the legal authority under state law to perform the service to be billed.1 Clarifi cation on the issue of legal authority will be covered under the defi nition of an advanced practice nurse, since states license APRNs, there is variation between states on the defi nition of an APRN. Rules for billing are compli- cated, scattered throughout Federal and State law, and vary from payer to payer.2 While this fact sheet will cover Medicare billing regulations, many insurers will follow Medicare guidelines. However, the APRN should remember that insurers may regulate reimbursement in their own way.

The history of APRN reimbursement is important to understand as it provides context to what follows. In 1990, direct APRN reimbursement by Medicare was available only in rural areas and skilled nursing facilities.3 In 1997, Medicare expanded reimbursement for Clinical Nurse Specialists (CNS) and Nurse Practitioners (NP; as well as nurse anesthetists and nurse midwives, however these

roles will not be covered in this fact sheet) to all geograph- ical and clinical settings allowing direct Medicare reim- bursement to the APRN, but at 85% of the physician rate.1 This success was won because of the powerful political ac- tion of the American Nurses Association, utilizing out- come data to show how CNS’ and NPs make a difference in cost and quality, and the political action partnerships established with specialty organizations and grassroots ac- tions of local nurses.

This fact sheet will provide an overview of reimburse- ment and issues related to billing for advanced practice nurse services. The regulatory environment is complex and APRNs should understand the regulations to maxi- mize reimbursement opportunities and investigate billing possibilities. It is important to note that in addition to federal billing guidelines, each state has licensing author- ity for APRNs and this licensing authority can be different depending upon the state in which the APRN practices. Each APRN will need to review their state licensing regula- tions 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 reimburse- ment issues as of the date it was written. It is hoped that this fact sheet will provide a starting place for the APRN to become acquainted with billing issues and opportunities, but is not meant to be an authoritative paper on all issues related to billing.

■ Defi nition: Advanced Practice Registered Nurses

The American Nurses Association (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 treatment of complex responses of individu- als, families or communities to actual or potential health problems, prevention of illness and injury, maintenance of

DOI: 10.1097/WON.0b013e3182478df0

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wellness and provision of comfort. The APRN has a mas- ter’s or doctoral degree concentrating in a specifi c area of advanced nursing practice, had supervised practice during graduate education, and has ongoing clinical experiences. APRNs include clinical nurse specialists, nurse practitio- ners, nurse anesthetists, and nurse midwives.4 While edu- cation, accreditation, and certifi cation are necessary components of an overall approach to preparing an APRN for practice; the licensing boards governed by state regula- tions and statutes-are the fi nal arbiters of who is recognized to practice within a given state. Currently, there is no uni- form model of regulation of APRNs across the states. Each state independently determines the APRN legal scope of practice, the roles that are recognized, the criteria for entry- into advanced practice, and the certifi cation examinations accepted for entry-level competence assessment. 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, Certifi cation, and Education5 has been en- dorsed by 41 nursing organizations, including the WOCN Society. The APRN Consensus Model defi nes advanced practice registered nurse practice, describes the APRN reg- ulatory model, identifi es the titles to be used, defi nes spe- cialty, describes the emergence of new roles and population foci, and presents strategies for implementation. This im- portant document should be accessed to see the recom- mendations that refl ect a need and desire to increase the clarity and uniformity of APRN regulation with hope that in the future this document will be used as a reference for regulatory issues. (See Table 1: Consensus Model: Defi nition of Advanced Practice Registered Nurse.)

An APRN may be prepared as a clinical nurse specialist, a nurse practitioner, a certifi ed nurse midwife, or a certifi ed

registered nurse anesthetist. This paper will utilize the term advanced practice nurse to only include the clinical nurse specialist and the nurse practitioner. The term pro- vider will include the APRN and the physician.

Medicare’s Defi nition and Qualifi cations of an APRN The following defi nition of an APRN is Medicare’s re-

quired qualifi cations.6 It appears that many other payer sources utilize Medicare’s APRN qualifi cations.

• Clinical Nurse Specialist:

� Is an RN currently licensed to practice in the State where he/she practices and is authorized to furnish the services of a CNS in accordance with State law.

� Has a Master’s degree or Doctor of Nursing Practice in a defi ned clinical area of nursing from an accred- ited educational institution and

� Is certifi ed as a CNS by a recognized national certi- fying body that has established standards for CNSs.

• Nurse Practitioner:

� Must be a registered professional nurse authorized by the state in which services are furnished to prac- tice as a NP in accordance with state law and meet one of the following

� Obtained Medicare billing privileges as a NP for the fi rst time on or after January 1, 2003 and

� Is certifi ed as a NP by a recognized national certify- ing body that has established standards for NPs and

� Has a Master’s degree in nursing or a Doctor of Nursing Practice degree.

� Obtained Medicare billing privileges as a NP for the fi rst time before January 1, 2003 and meets the cer- tifi cation requirements described above, or

� Obtained Medicare billing as a NP for the fi rst time before January 1, 2001.

TABLE 1.

Consensus Model: Defi nition of Advanced Practice Registered Nurse

The defi nition of an Advanced Practice Registered Nurse (APRN) is a nurse:

1. Who has completed an accredited graduate-level education program preparing him/her for one of the four recognized APRN roles; 2. Who has passed a national certifi cation examination that measures APRN, role and population-focused competencies and who maintains

continued competence as evidenced by recertifi cation in the role and population through the national certifi cation program; 3. Who has acquired advanced clinical knowledge and skills preparing him/her to provide direct care to patients, as well as a component of

indirect care; however, the defi ning factor for all APRNs is that a signifi cant component of the education and practice focuses on direct care of individuals;

4. Whose practice builds on the competencies of registered nurses (RNs) by demonstrating a greater depth and breadth of knowledge, a greater synthesis of data, increased complexity of skills and interventions, and greater role autonomy;

5. Who is educationally prepared to assume responsibility and accountability for health promotion and/or maintenance as well as the assessment, diagnosis, and management of patient problems, which includes the use and prescription of pharmacologic and non- pharmacologic interventions;

6. Who has clinical experience of suffi cient depth and breadth to refl ect the intended license; and 7. Who has obtained a license to practice as an APRN in one of the four APRN roles: certifi ed registered nurse anesthetist (CRNA), certifi ed

nurse-midwife (CNM), clinical nurse specialist (CNS), or certifi ed nurse practitioner (CNP).

Approved by the WOCN Board of Directors: September 20, 2011

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The national certifying bodies that Medicare recognizes are:7

• The American Nurses Credentialing Center, • The National Certifi cation Corporation for Obstet-

rics, Gynecologic, and Neonatal Nursing Specialties, • The American Academy of Nurse Practitioners, • The Pediatric Nursing Certifi cation Board (formerly

National Certifi cation Board of Pediatric Nurse Practitioners and Nurses),

• The Oncology Nursing Certifi cation Corporation, • The Critical Care Certifi cation Corporation now

called AACN Certifi cation Corporation, and • National Board of Certifi cation of Hospice and Pal-

liative Nurses.

Medicare Coverage Criteria for Medicare Services Furnished by Advanced Practice Registered Nurse The following are the Medicare required APRN coverage criteria: 6

• Services or supplies that must be medically reason- able and necessary:

� Are proper and needed for the diagnosis or treat- ment of the benefi ciary’s medical condition,

� Are furnished for the diagnosis, direct care and treatment of the benefi ciary’s medical condition,

� Meet the standard of good medical practice, and

� Are not mainly for the convenience of the benefi – ciary, provider, or supplier.

• The following must be met:

� Services are performed in collaboration with a phy- sician. Collaboration occurs when the APRN works with one or more physicians to deliver health care services within the scope of their professional ex- pertise. Medical direction and appropriate supervi- sion is provided as required by the law of the state in which the services are furnished (it is not re- quired for the collaborating physician to be present when services are furnished or to independently evaluate patients).

� Services are the type considered physician’s ser- vices if furnished by a medical doctor or a doctor of osteopathy,

� Services are not otherwise precluded due to a statu- tory exclusion, and

� He or she is legally authorized and qualifi ed to furnish the services in the state where they are performed.

Additionally, a nurse practitioner may be selected as a hospice benefi ciary’s attending physician, but he/she can- not certify or recertify a terminal illness with a prognosis of six months or less.

The APRN may bill the Medicare program directly for services using his/her national provider identifi er (NPI) or under an employer’s or contractor’s NPI. A NPI is a unique

10-digit identifi cation number issued to health care pro- viders in the United States by the Centers for Medicare and Medicaid Services (CMS). The NPI has replaced the unique provider identifi cation number (UPIN) as the required identifi er for Medicare services, and is used by other pay- ers, including commercial healthcare insurers. A NPI may be applied for at https://nppes.cms.hhs.gov. If billing is done via “incident to” services, these claims must be sub- mitted under the supervising physician’s NPI and identi- fi ed on provider fi le by specialty code 50 for nurse practitioners and 89 for clinical nurse specialists. “Incident to” billing is beyond the scope of this fact sheet; for infor- mation on incident to billing, refer to the WOCN Society fact sheet entitled: “Understanding Medicare Part B ‘Incident to’ Billing.” (In press, 2011.)

Payment is made only on an assignment basis, which means that payment will be the Medicare allowed amount as payment in full and the APRN may not bill or collect from the benefi ciary any amount other than unmet co- payments, deductibles, and/or coinsurance. Services are paid at 85% of the Medicare Physician Fee schedule amount. When services furnished to hospital inpatients and outpatients are billed directly, payment is unbundled and made to the APRN.

Advanced Practice Nurses must enroll in the Medicare program to be eligible to receive Medicare payment for cov- ered services provided to Medicare benefi ciaries. Form CMS- 8551 is used for physicians and non-physician practitioners (i.e., APRNs) to initiate the Medicare enrollment process. If the APRN is part of a clinic or group practice, Form CMS 855B is used to initiate the enrollment process. There is an Internet based Provider Enrollment, Chain and Ownership System (PECOS) that can be used. For many APRNs this en- rollment process is initiated by their employer.8

The APRN must understand and meet the state licens- ing requirements in the state where his/her delivery of services will take place, must meet the Medicare require- ments to bill Medicare, and have a NPI. Reimbursement by private insurance companies is separate from the Medicare process and may require a credentialing process.

■ Credentialing and Privileging

Provider credentialing and privileging is a practice in which documented recognition and verifi cation is admin- istered to a practicing professional. The credentialing sys- tem is used by various organizations and agencies to ensure that their health care practitioners meet all the nec- essary requirements and are appropriately qualifi ed. This process frequently occurs before the provider is hired. It is used to confi rm the provider’s license, education, training, decision-making, and overall quality. The process varies between facilities but may include completion of an ap- plication for credentialing and privileging, primary source verifi cation of credentials, review board and approval. The application may include a curriculum vitae, copy of current

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licensure, verifi cation of graduation from approved pro- gram, copy of certifi cation, letters of recommendation, mal- practice history, and other documents as identifi ed by the place of employment. Health care facilities set their own guidelines regarding how often a provider is re-credentialed to maintain their status.

■ APRN Inpatient Reimbursement

The following principles on inpatient APRN reimburse- ment are based on Medicare rules. Not all payers follow Medicare rules and this includes Medicaid. Hospitals plan- ning to bill Medicaid, may query state Medicaid and com- mercial payers about their rules and policies.2

Medicare inpatient hospital billing principles are iden- tifi ed as:

1. The service must be a physician service. 2. The service cannot be just one part of a bundled

service. 3. The service must be within the APRN’s scope of

practice under state law. State laws specify the physician services that APRNs are authorized to perform and each state’s defi nition is slightly dif- ferent.

4. The service must be medically necessary. 5. The APRN must meet the payer’s credentialing re-

quirements. 6. Documentation of the service must conform to

the payer’s requirements for the procedure code billed.

7. Generally, the APRN’s services should be billed under the APRN’s provider number. However, there are exceptions to this statement.

8. It is permissible to bill visits “shared” with physi- cians, under certain conditions.

9. Medicare will pay only one charge per day, per patient, per specialty, for Evaluation and Manage- ment billing.

10. A hospital may not bill Medicare Part B for an APRN’s services if the hospital receives any reim- bursement for the APRN’s salary under the hospi- tal cost report.

11. The services of residents, nursing students, medi- cal students, physician assistant students and APRN students cannot be billed under an APRN’s provider number.

12. Employment relationships affect who has the right to bill for an APRN’s services.

13. 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 physician services. Nursing services are reim- bursed through prospective payments or payments based on direct Diagnosis Related Groups (DRG). If an APRN per-

forms a complicated dressing change or pouching proce- dure, which is a nursing service, it is not a billable service. That service is covered by the DRG payment or the per diem payment to the hospital. Medicare prospective pay- ments 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.

Provider services are reimbursed separately from other services provided in hospitals. Medicare payments for pro- vider services are reimbursed through Medicare Part B. Provider services are defi ned by Federal regulations as di- agnosis, therapy, surgery, consultation, care plan over- sight; and home, offi ce and institutional visits. Charges for inpatient services are done using the Current Procedural Terminology (CPT) code system. The Evaluation and Management (E&M) service is the most common service provided by an APRN in the hospital. The E&M service includes history taking, examination, medical decision- making (diagnosis and therapy) counseling, and coordina- tion of care. CPT procedural codes can be billed by any qualifi ed provider.

The hospital can bill for the APRN’s services under the physician/provider payment system if the salary and ben- efi ts of the APRN are not reimbursed under the hospital’s cost report. The salary of the APRN must be unbundled from the hospital’s cost report. The hospital cannot bill Medicare if the APRN’s salary is being reimbursed under Part A of Medicare.1,2

There are some services provided by the APRN that are physician services but are not billable. For example, “rounding” is a physician service but not billable. Initiating transfers and writing transfer orders are physician services but are not billable. Writing orders to change an intrave- nous solution is not a billable service. There are no separate CPT codes for these services. These services are part of the package of treatment and communication services bun- dled together and identifi ed by the CPT codes for E&M.

When an APRN evaluates and manages a patient’s illness or injury through history taking, examination and medical decision making, the work is billable because all of the re- quired elements of the service have been performed. If an APRN changes a dose of digoxin based on the laboratory re- sults from earlier in the day, it is considered a provider service (medical decision-making). However, if the documentation is lacking the history or examination, the service is not bill- able because it is just one part of a package of services or E&M bundled together for reimbursement purposes.2

Hospital discharges are billable if the service includes performing the fi nal examination of the patient, discussion of the hospital stay, instruction for continuing care to all caregivers, prescriptions and referral forms and preparation of discharge records. However, if the APRN simply dictates the discharge summary and/or orders without performing the other functions, the APRN’s services are not billable.

Medicare and other payers will reimburse providers for items or services that are “reasonable and necessary for a

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diagnosis or injury or to improve the functioning of a mal- formed body member.”9 Both the medical record and billing claim must describe or indicate why the service was neces- sary. Administrators of Medicare, Medicaid, and commercial insurers may have policy level input into ordering decisions. Local Medicare contractors may specify the clinical circum- stances under which a service is considered reasonable and necessary. Policies may vary from region to region.

Shared or split billing in the hospital inpa- tient/outpatient/emergency department setting. When an E&M is shared between a physician and APRN from the same group practice and the physician provides any face to face portion of the E&M encounter with the patient, the service may be billed under the physician’s or the APRN’s NPI number. However, if there was no face-to- face encounter between the patient and the physician (for instance, the physician only reviewed the chart), then the service may only be billed under the APRN’s NPI entered on the claim. An example is if the APRN sees the patient in the morning and the physician performs a face to face in the afternoon on the same day, the physician or the APRN may report the service.

If a hospital or medical practice bills for an APRN ser- vice when another provider has already billed that same service one of the bills may be denied. Therefore, it is nec- essary for the APRN and physician to coordinate their vis- its. If an APRN performs sections of the E&M and a provider of the same specialty then repeats that exam or adds to the APRN service, there is a choice to be made. Either the ser- vice 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 em- ployed by different groups and both groups submit bills, the second bill to arrive at the payer’s offi ce will be denied.

If the APRN is performing pre-operative examinations and post-operative E&M for surgical patients, this is in- cluded in the global surgical package for major surgery. The global surgical package is a fi xed fee to cover all treatment and services related to the surgical procedure including pre-operative visits after the decision is made to operate beginning with the day before the surgery, intraoperative services, and complications following surgery. The time frame depends upon the surgical procedure and is 90 days, 10 days or 0 days; with major surgery, the global period is 90 days; and minor surgery varies between 0-10 days.9

■ Current Procedural Terminology Codes

Medicare Billing is done using either current procedural terminology (CPT) codes or evaluation and management (E&M) codes. This section will cover current procedure ter- minology, evaluation and management codes will follow.

Current procedural terminology (CPT) codes are a sys- tematic listing and coding of procedures/services per- formed by providers that serve as the basis for health care

billing. CPT codes are developed, maintained, and copy- righted by the American Medical Association (AMA). The fi ve-digit number assigned to each code refers to a specifi c service or procedure that a provider may supply to a pa- tient including medical, surgical, and diagnostic services. The purpose of the CPT code is to provide a uniform lan- guage that accurately describes services rendered. The uni- form language serves as an effective means for reliable nationwide communication between medical practitio- ners, patients, and third parties.11 Third parties (e.g., insur- ers) use the CPT codes to determine the amount of reimbursement to be paid to the practitioner.

In the CPT codebook, sold only by AMA or AMA des- ignees, codes are listed in six sections or code sets. These code sets are then sub-sectioned by anatomic, procedural, condition, or descriptor subheadings. Services and proce- dures, with their identifying codes, are listed in numeric order with the exception of the Evaluation and Management (E&M) codes. E&M codes, which are num- bered 99201-99249, are listed at the beginning of the code sets as these codes are the most frequently used by medical practitioners for reporting services.

At the beginning of each code set, specifi c guidelines identify items that are necessary for appropriately inter- preting and reporting the services and procedures within that set. The guidelines may include information such as settings of services (e.g., offi ce, hospital, etc.), special re- ports 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 specifi c code. Diligence is required in selec- tion of the appropriate code for services rendered since the code reported dictates the amount of reimbursement.

On occasion, there are services or procedures that are not found in the CPT codebook. For that reason, the AMA has designated several specifi c code numbers for reporting unlisted services/procedures, which should be described using the section specifi c guidelines. The CPT codes are up- dated annually to include new services and/or procedures and to remove obsolete ones. Therefore, the designated un- listed service/procedure codes are monitored by the AMA for recurrent use. Repeated and frequent use of the code may lead to the development of a CPT for that service/procedure.

Some procedural codes are commonly carried out in addition to the primary procedure performed. Add on codes describe additional intra-service work associated with the primary procedure and must be performed by the same provider. A descriptor of an add-on code would con- tain phrases like “each additional” or “list separately in addition to primary procedure code.”

Modifi ers can also be added to CPT codes as a means of reporting or indicating that a service/procedure rendered has been altered by some specifi c circumstance but that it did not change the defi nition or code. The modifi ers allow medical practitioners to effectively respond to payment policy requirements established by other entities. The modifi ers have specifi c numeric identifi ers (listed in the

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appendices of the codebooks) and cover one of the follow- ing alterations in the service/procedure:

• Service/procedure had both a professional and tech- nical component.

• Service/procedure was performed by more than one provider and/or in more than one location.

• Service/procedure was increased or reduced. • Only part of a service was performed. • An adjunctive service was performed. • A bilateral procedure was performed. • Service/procedure was provided more than once. • Unusual events occurred.11

APRNs seeking specifi c codes related to services and/or procedures provided in the WOC nursing arena, will fi nd no specifi c codes for ostomy care. E&M codes will have to suffi ce at this time. There are codes related to wounds and continence services. The following two examples are pro- vided as a guide in using the CPT codebook.11

Section/code 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 by the surface area of the wound. These services may be reported for inju- ries, infections, wounds, and chronic ulcers. When per- forming debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths. For example, when a bone is debrided from a 4 sq cm heel ulcer and from a 10 sq cm ischial ulcer, report the work with a single code, 11044. When subcutaneous tissue is debrided from a 16 sq cm dehisced abdominal wound and a 10 sq cm thigh wound, report the work with 11042 for the fi rst 20 sq cm and 11045 for the second 6 sq cm. If all four wounds were debrided on the same day, use modifi er 59 with 11042, 11045, and 11044.11

Debridement Codes: 11042: Debridement, subcutaneous tissue (includes epidermis and dermis, if performed): fi rst 20 sq cm or less.

11045: Each additional 20 sq cm, or part thereof. (List separately in addition to code for primary 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 treatment by pulsing magnetic neuromodulation, use code 53899.)11

■ Evaluation and Management Services Codes

The CPT codes which describe physician-patient encoun- ters are often referred to as Evaluation and Management Codes. Evaluation and Management Services refer to visits and consultations furnished by providers. A provider’s Medicare benefi t allows him/her to bill for E&M services and the services must be 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’s insur- ance coverage and to validate the place of service, the medical necessity and appropriateness of the diagnostic and/or thera- peutic services provided. It is also necessary to document that the services provided have been accurately reported.

Documentation of each patient’s encounter should in- clude seven key components:

• The chief complaint or reason for the visit and relevant history;

• Physical examination fi ndings and prior diagnostic test results;

• Medical decision making; • Counseling; • Coordination of care; • Nature of presenting problem; and • Time spent with the patient.

Included should also be the assessment, clinical impression or diagnosis, medical plan of care and date, and legible identity of the observer. Appropriate health risks should be identifi ed. If not charted, the rationale for ordering diagnostic and other ancillary services should be easily inferred. Past and present diagnoses should be easily accessible to the treating and con- sulting providers. The patient’s progress, response to and changes in treatment, along with the revision of diagnosis should be documented. The diagnosis and treatment codes re- ported on the health insurance claim form or billing statement should be supported by the documentation on the medical record. It is the responsibility of the provider to ensure that the submitted claim is correct and refl ects the services provided. A billing specialist or alternate source may review the docu- mented services before the claim is submitted to the payer.

E&M services are arranged into different settings depend- ing on where the service is provided. Examples include, offi ce or outpatient setting; hospital inpatient; emergency depart- ment; and nursing facility. Patients are identifi ed as either new or established depending on previous encounters with the provider or the provider’s group.

The code sets used to bill for E&M services are organized into various levels and categories. The more complex the visit, the higher the level of code that the provider may bill within the appropriate category. The volume of charting does not dictate the level of billing. The services must meet the defi nition of the code.

There are three key components required when select- ing the appropriate level of E&M service provided: history, examination, and medical decision making. Visits that

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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.

type of medical decision-making, two of the three ele- ments must either be met or exceeded.

When counseling and/or coordination of care takes more than 50% of the provider/patient and/or family

The levels of E&M services are based on four types of examinations: problem focused, expanded problem focused, detailed, and comprehensive. The type and extent of the ex- amination 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 be used (but not both) by the provider for a patient encounter. The most substantial difference between the two versions is in the examination section. Any provider, regardless of spe- cialty, may perform both types of examinations. It is impor- tant to keep in mind with both the 1995 and 1997 documentation guidelines, that noting an abnormal or un- expected fi nding in an examination requires further descrip- tion, whereas a brief statement or notation indicating a negative or normal fi nding is suffi cient for documentation related to unaffected areas or asymptomatic system(s).12,13

Medical decision-making refers to the complexity of mak- ing a diagnosis and/or selecting management choice. This is determined by considering the following factors: number of possible diagnoses or management options, the amount and/ or complexity of medical records, diagnostic tests and/or other information that must be obtained, reviewed, and in- vestigated, the risk of signifi cant complications, morbidity, and/or mortality as well as co-morbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the potential management options.

Below is a chart that lists the elements of each level of medical decision making. Note that to qualify for a given

encounter (face-to-face time in the offi ce or other outpa- tient setting, fl oor/unit time in the hospital or nursing home), the time is considered the key or controlling factor to qualify for a particular level of E&M service. The total length of time of the encounter should be documented and the record should describe the counseling and/or ac- tivities to coordinate care. The Level I and Level II CPT books available from the AMA lists average time guide- lines for a variety of E&M services. These times include work performed before, during and after the encounter.

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

For offi ce/clinic setting encounters with established pa- tients that meet the “incident to” requirements, report using the physician’s National Provider Identifi er (NPI). For encounters that do not meet “incident to” criteria, re- port using the APRN’s NPI. In the hospital inpatient, out- patient and Emergency Department (ED) setting encounters shared between a physician and an APRN from the same group practice, when the physician provides any face-to- face portion of the encounter, report using either provid- er’s NPI. When the physician does not provide a face-to-face encounter, then report using the APRN’s NPI.14-16

■ Liability (Malpractice) Insurance

APRNs (as with all other practitioners who provide medical services/procedures) are working in a lawsuit driven

Type of Decision Making Number of Diagnoses or

Management Options Amount and/or Complexity of

Data to be Reviewed Risk of Signifi cant Complications,

Morbidity, and/or Mortality

Straightforward Minimal Minimal or None Minimal

Low Complexity Limited Limited Low

Moderate Complexity Multiple Moderate Moderate

High Complexity Extensive Extensive High

Type of History Chief Complaint History of Present

Illness Review of Systems Past, Family, and/or

Social History

Problem Focused Required Brief N/A N/A

Expanded Problem Focus

Required Brief Problem Pertinent N/A

Detailed Required Extended Extended Pertinent

Comprehensive Required Extended Extended Complete

TABLE. 2

Types of History

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environment. There are numerous factors that contribute to the risk for being named in a lawsuit, among them are patient load, voluminous paperwork associated with care provided, and staffi ng shortages. One negative outcome, whether real or perceived by the patient or caregiver, can easily result in a lawsuit. Professional liability (malpractice) insurance can protect the practitioner’s family, savings, personal belongings, home, and any other assets of value.

Institutions, such as medical centers and/or hospitals, long-term care facilities and/or home health agencies, carry “blanket” liability on employees but the primary purpose of this insurance is to protect the employing agency. If a med- ical lawsuit is fi led 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 fi nances.

In addition, an employer’s policy does not protect the APRN’s license to practice. Confl ict of interest can arise between the APRN and the employer itself. For instance, if being named jointly with an employer in a lawsuit, the employer can argue that facility’s procedures were not followed to the letter. Maintaining that argument can devastate the practitioner’s career, even if the case is dis- missed from court or the practitioner is acquitted of mal- practice. The employer would retain the right to fi le a complaint against the practitioner to his/her licensing body (i.e., the state’s Board of Nursing). An investigation will be triggered and the practitioner will be required to hire his/her own defense attorney. If the Board decides to fi le disciplinary action against the practitioner, his/her career as an APRN could be tainted or ruined.

APRNs should question their actual or potential em- ployer about the policy carried to cover them as employ- ees. The following are issues to investigate:

1. Is the APRN protected individually under the poli- cy (specifi cally named as an insured party)?

2. Does the insurance include License Protection to help with defense of the APRN in an administrative or disciplinary situation?

3. If the APRN leaves the employment of the facility/ agency, does the policy cover for an incident that occurred while still employed (is the employer’s policy “Occurrence”)?

4. Does the APRN have individual limits of liability? 5. What level of coverage does the APRN have with

the policy (per incident, per lifetime, etc.)? 6. Ask to see the policy (if the APRN has a personal

attorney, can he/she review the policy)? 7. Does the policy cover 24 hours/day? 8. What is the employer’s insurance company’s stabil-

ity rating?17

APRNs are held legally accountable to their scope of prac- tice and are therefore facing greater malpractice exposure than ever before, especially in two key areas:

1. Diagnostic Responsibilities – greater numbers of APRNs are able to work in a collaborative agree- ment rather than working for a physician in a com- plementary role.

2. Prescriptive Authority – APRNs can prescribe under their own signature in many states.

To date, APRN liability (malpractice) insurance premi- ums 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 practitio- ners of any level are named in lawsuits, insurers will 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 mini- mal as well as maximal coverage for their practice, which is generally based on risk association for the type practice (some areas of practice have higher litigious rates and therefore higher premiums). While negotiating a contract, liability (malpractice) insurance coverage is a key issue to be addressed. APRNs can request the employer to provide individual liability insurance as a part of their benefi t pack- age as long as it truly meets the APRNs coverage needs.

■ “Incident to” Billing

“Incident to” refers to a Medicare billing mechanism, al- lowing services furnished in an outpatient setting to be provided by auxiliary personnel and billed under the pro- vider’s NPI number. The provider can be a physician, nurse practitioner, clinical nurse specialist, physician’s assistant, nurse midwife, and clinical psychologist. The services pro- vided 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 supervi- sion. The provider must initiate a course of treatment and the services done by the auxiliary staff include follow up care, and assisting in the plan of care. In some outpatient settings, there may be an opportunity for a non-provider (i.e., non-APRN) to provide care and obtain reimburse- ment as “incident to” the provider’s services. The provider can be a physician or an advanced practice nurse so there may be opportunities for an APRN to direct care of pa- tients with wound, ostomy and continence care issues and for non-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 physician’s infor- mation and this makes it diffi cult 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.)

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■ Summary

Understanding and in some cases pursuing reimbursement for advanced practice nursing services may be key for sur- vival in today’s health care environment. To be prepared to participate in today’s health care industry, APRNs need to be competent clinicians but also need to be well versed in the business side of providing care. Understanding the key concepts of APRN defi nition, Medicare billing regulations, other insurance’s regulations, credentialing for privileges in the health care setting, inpatient versus outpatient bill- ing issues, the use of CPT codes, and other topics as defi ned by the specifi c 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 authority on this subject. The information provided may change, depending on the current reimbursement envi- ronment and it is suggested that the reader seek out the references and additional reading resources listed below.

■ References 1. Balanced budget act of 1997. http://www.gpo.gov/fdsys/pkg/

PLAW-105publ33/pdf/PLAW-105publ33.pdf 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.

3. Frakes, Evans T. An Overview of Medicare Reimbursement Regulations for Advanced Practice Nurses, 2006. http://www.med- scape.com/viewarticle/531035

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

5. APRN Consensus Work Group, & National Council of State Boards of Nursing APRN Advisory Committee. Consensus model for APRN regulation: Licensure, accreditation, certifi ca- tion & education, 2008. https://www.ncsbn.org/Consensus_ Model_for_APRN_Regulation_July_2008.pdf.

6. 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.

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

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

9. 42 Code of Federal Regulations (CFR), section 410.2. 2005. http://edocket.access.gpo.gov/cfr_2005/octqtr/pdf/42cfr410. 21.pdf. Accessed March 8, 2011.

10. Centers for Medicare & Medicaid Services (CMS). General bill- ing requirements in Medicare claims processing manual sec- tion 30.3.12.1. https://www.cms.gov/manuals/downloads/ clm104c01.pdf. Accessed March 8, 2011.

11. CPT Codebook 2011, AMA. 12. Medicaid Learning Network (MLN). 1995 Documentation

Guidelines for Evaluation & Management Services, 1999. http://www.cms.gov/MLNProducts/Downloads/1995dg.pdf.

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

14. Centers for Medicare & Medicaid Services (CMS). (2010). Evaluation and Management Services Part B. http://www.trail- blazerhealth.com/Publications/Training%20Manual/ EvaluationandManagementServices.pdf.

15. Medicaid Learning Network (MLN). (n.d.). http://www.cms .gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf.

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

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

18. Reimbursement for Nurse Practitioner Services Position Statement. J Pediatr Health Care. 2004;18:27A-28A.

■ Additional Reading

Coalition for Nurses in Advanced Practice (n.d.). Reimbursement: General information. Retrieved July 25, 2010 from http://www.cnaptexas.org/displaycom- mon.cfm?an�1&subarticlenbr�17

Kennerly, S. (2007). The impending reimbursement revo- lution: How to prepare for future APN reimbursement. Nursing Economics, Mar/Apr 2007, 25:2, 81-84.

Lilley, C. (2009). APN reimbursement, April 15, 2009 Presentation by Christa Liley-Kennedy Group 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 change one nurse at a time. The Nurse Practitioner: The American Journal of Primary Health Care, Feb: 2009 34:1,9.

Phillips, S. 22nd annual legislative update regulatory and legislative successes for APNs. The Nurse Practitioner: The America Journal of Primary Health Care, Jan: 35:11, 24-47.

Plager, K. A., & Conger, M. M. (2007). Advanced practice nurs- ing; constraints to role fulfi llment. The Internet Journal of Advanced Practice Nursing, 2007, 9:1-8. Retrieved March 31, 2011, from http://www.ispub.com/journal/the_internet_ journal_of_advanced_nursing_practice/volume_9_ number_1_3/article/advanced_practice_nursing_con- straints_to_role_fulfi llment.html

Schaumm, K. (2009). Does your hospital-owned outpatient wound care department have the required “direct super- vision?” Advances in Skin and Wound Care, 1:6, 256-254.

Sullivan, E. M. (2008). Lessons learned from advanced practice nursing payment. Policy, Politics and Nursing Practice. 9:2, May 2008, 121-26.

Vargo, D. (2010). Direct supervision requirements and in- cident to services a primer for the WOC nurse. JWOCN, March/April 2010, 148-51.

■ Glossary

Advanced Practice Registered Nurse (APRN): A reg- istered nurse, licensed by the state in which they practice who has completed an accredited graduate level educa- tional program preparing her/him for one of the four

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Copyright © 2012 Wound, Ostomy and Continence Nurses Society. Unauthorized reproduction of this article is prohibited.

recognized advanced practice roles, clinical nurse special- ist, nurse practitioner, nurse midwife, or nurse anesthetist. The APRN has passed a national certifi cation examination that measures APRN, role and population focused compe- tencies and who maintains continued competence as evi- denced by recertifi cation in the role and population through the national certifi cation programs. (Adapted from the LACE consensus model.)5

Credentialing: A method to document recognition and verifi cation of a provider’s qualifi cations to practice in a health care setting.

Current Procedural Terminology (CPT): Systematic listing and coding of procedures/services performed by pro- viders that serve as the basis for health care billing.

E&M Services: Evaluation and management services are CPT codes which describe physician-patient encounters are often referred to as Evaluation and Management Codes. Evaluation and Management Services refer to visits and consultations furnished by providers.

Hospital Cost Report: All Medicare certifi ed institu- tional providers are required to submit an annual cost re- port to the Fiscal Intermediary. The report contains information such a facility characteristics, utilization data, cost, and charge by cost center and fi nancial statement data. This information is used by Medicare to provide

reimbursement, collect statistics, and make future deci- sions upon reimbursement.

International Classification of Disease, Diagnosis, and Procedural Codes (ICD-10): Is a re- placement for ICD-9-CM diagnosis and procedure codes. It will 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 el- derly and disabled. There are two Medicare programs, Part A: covers hospitalization, hospice, skilled nursing facilities and some home care services and Part B, which covers phy- sician services, outpatient hospital services, laboratory charges, medical equipment, and other home health ser- vices. The Medicare programs are administered by the Center for Medicare and Medicaid Services (CMS). Medicare Part A is managed by a contracting agency called an inter- mediary agency; Medicare Part B is managed by a contract- ing agency called a carrier.

Medicaid: State administered program for low-in- come families and children, pregnant women, the aged, blind and disabled and long-term care.

NPI Number: Unique identifi cation 10 digit numeric ID for covered health care providers. Information: www. cms.gov/nationalprovidentstand/

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