Medicare should increase the reimbursement rate of NPs to 100% of the physician payment rate. Current Medicare reimbursement for NPs comes from the Balanced Budget Act (1997)MedPAC meets frequently and issues two reports to Congress each year. CPT codes are developed, maintained, and copyrighted by the American Medical Association (AMA). CNMs received reimbursement of 65%, while NPs and PAs received reimbursement of 85% of the physician rate (Figure 1). Insurance carriers charge a one-time fee to extend the coverage, which can cost as much as 1.5 to 2.0 times the annual policy premium of the final year of coverage. Abstract. This is the time for NPs to seize the opportunity to work with MedPAC to achieve full reimbursement for care provided. Hospital Cost Report: All Medicare certified institutional providers are required to submit an annual cost report to the Fiscal Intermediary. Potentially preventable hospitalizations in Medicare patients with diabetes: A comparison of primary care provided by nurse practitioners versus physicians. doi: 10.1016/j.nurpra.2014.09.007, Fodeman, J., & Factor, P. (2015). A descriptor of an add-on code would contain phrases like each additional or list separately in addition to primary procedure code.. Dr. Greenberg is a Fellow in the American Academy of Nursing, American Association of Nurse Practitioners, Gerontological Society of America, and New York Academy of Medicine, as well as Distinguished Educator in Gerontological Nursing through the National Hartford Center of Gerontological Nursing Excellence. Medicare provides two billing options for services provided by APPs: 1. 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. 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). Research has shown that NPs provide quality, cost effective care with a favorable patient experience (Kippenbrock et al., 2019) (See Table 1). to maintaining your privacy and will not share your personal information without Citation: Bischof, A., Greenberg, S.A., (May 31, 2021) "Post COVID-19 Reimbursement Parity for Nurse Practitioners" OJIN: The Online Journal of Issues in Nursing Vol. Medicare Billing is done using either current procedural terminology (CPT) codes or evaluation and management (E&M) codes. The impending reimbursement revolution: How to prepare for future APN reimbursement. The role of nurse practitioners in reinventing primary care. Centers for Medicare & Medicaid Services (CMS). 12. The number of states granting full practice authority to NPs is growing. Incident to Billing NPs have been providing care for Medicare patients since its inception in1965.NPs have been providing care for Medicare patients since its inception in1965. Balanced Budget Act of 1997, Pub. Resources for Peer Reviewers and Editorial Board, JWOCN Manuscript Checklist - Original Research, JWOCN Manuscript Checklist - Clinical Challenges Feature Article, JWOCN Manuscript Checklist - Scoping & Systematic Review. It is the responsibility of the provider to ensure that the submitted claim is correct and reflects the services provided. It will be used for services provided on or after October 1, 2013, for all Health Insurance Portability and Accountability Act covered entities. Why is the Medicare reimbursement rate for NPs still 85%? your express consent. 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). Evaluation and Management Services refer to visits and consultations furnished by providers. Medicare program integrity manual chapter 15 Medicare enrollment #100-08, 2011. Retrieved from: http://www.medpac.gov/docs/default-source/reports/jun02_NonPhysPay.pdf?sfvrsn=0, Medicare Payment Advisory Commission (MedPAC). 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). National Board of Certification of Hospice and Palliative Nurses. More info. Reimbursement is a complex structure that includes regulatory factors both at the state and federal level. The total length of time of the encounter should be documented and the record should describe the counseling and/or activities to coordinate care. The following two examples are provided as a guide in using the CPT codebook.11, Wound debridement (codes: 11042-11047) is reported by the depth of tissue that is removed and by the surface area of the wound. APRNs include clinical nurse specialists, nurse practitioners, nurse anesthetists, and nurse midwives.4 While education, accreditation, and certification are necessary components of an overall approach to preparing an APRN for practice; the licensing boards governed by state regulations and statutes-are the final arbiters of who is recognized to practice within a given state. For example, rounding is a physician service but not billable. We consider MedPAC and reimbursement policy, post COVID-19 policy solutions, and action steps to move forward to seek reimbursement parity. Resources: Family Nurse Practitioner Private Practice Family care is the most common specialization among nurse practitioners, with nearly 70% of NPs holding their primary certification in this area, according to AANP. Dr. Greenberg is a nurse practitioner faculty consultant on the Institute for Healthcare Improvements Age-Friendly Health Systems initiative. By clicking "Allow All" you agree to the storing of cookies on your device to enhance site navigation, Reimbursement North Carolina law has mandated the reimbursement of nurse practitioners, certified nurse midwives and psychiatric-mental health clinical nurse specialists by indemnity insurance plans since 1994. What is the employer's insurance company's stability rating? In this interview conducted at Pittcon 2023 in Philadelphia, Pennsylvania, we spoke to Ron Heeran, a speaker at the 2023 James L. Waters Symposium. Almost 90% of NPs are certified in primary care and 69% actually provide primary care. By continuing to browse this site you agree to our use of cookies. Medicare payments for provider services are reimbursed through Medicare Part B. Lilley C (2009). However, with nurse managed clinics, the overhead cost may need to be re-examined (See Tables 1 and 2). 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). To bill this way, certain rules must be followed. 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. Because visits that are billed incident to are reimbursed at 100%, and visits billed under an NP provider number are billed at 85%, Medicare would save a substantial amount of money by eliminating incident to billing. Retrieved June 3, 2010, from. Survey results will be used to improve workforce planning and advocate for payment parity legislation requiring health plans to pay ARNPs the same as physicians for the same service. The Oncology Nursing Certification Corporation, The Critical Care Certification Corporation now called AACN Certification Corporation, and. Medicare should increase the reimbursement rate of NPs to 100% of the physician payment rate. The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by the documentation on the medical record. Thus, their recommendation was to continue with the 85% reimbursement rate (MedPAC, 2002). Patients are identified as either new or established depending on previous encounters with the provider or the provider's group. The Evaluation and Management (E&M) service is the most common service provided by an APRN in the hospital. Congress has not yet acted on their recommendation. This is a start to establish the evidence that NPs can indeed produce the same product as physicians. 16. This policy helps cover the costs of injuries and property . This article offers a review of the issues, such as incident to billing; direct and indirect reimbursement; and quality of care. To maximize the utilization of APRNs as PCPs, the payment system should be remodeled. "Such studies can then be used to support further evolution of reimbursement policy, if NPs indeed produce an equal or better product than physicians," she says. The most stressful part, in relation to insurance reimbursement, is that most healthcare providers like nurse practitioners are not formally trained in billing and coding and work in a clinical setting or facility with no certified billing and coding specialists. Physicians have higher cost associated with training, office overhead, and malpractice premiums (MedPAC, 2019b). $5,000 in property damage per accident. As the number of NPs continued to rise, removing the location barrier was a great feat (Apold, 2011). Nurse lobbying groups compromised on the NP reimbursement rate of 85% of the physician fee because the location restriction for NP care was removed. Retrieved from: http://www.medpac.gov/docs/default-source/reports/jun19_medpac_reporttocongress_sec.pdf?sfvrsn=0, Medicare Payment Advisory Commission (MedPAC). There are codes related to wounds and continence services. A growing number of states are granting full practice authority to nurse practitioners. 15. The numbers keep growing with over 28,700 recent graduates in 2018 (AANP, 2020). She also outlines the potential benefits of providing NPs with 100% reimbursement, including incentivizing them to practice in primary care settings where there is a shortage. Reimbursement issues for nurse practitioners can often be traced back to incomplete documentation, resulting in denied claims, decreased profitability, and reduced patient satisfaction. The 85% reimbursement policy is supported by the rationale that physicians have higher student loans, pay practice overhead cost, have higher malpractice premiums, and care for more complex patients (MedPAC, 2002). analyse site usage and support us in providing free open access scientific content. 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. Defendant Expense Benet - up to $25,000 annual aggregate, up to $1,000 per day. The COVID-19 pandemic led many states to lift restrictions on NP practice. Report to the Congress: Medicare and the Healthcare Delivery System. The type and extent of the examination performed is based upon clinical judgment, the patient's history, and the nature of the presenting problem. This section will cover current procedure terminology, evaluation and management codes will follow. Lessons learned from advanced practice nursing payment. Commercial Insurance - Health Care Reimbursement - Guides at Johns Hopkins University. The term provider will include the APRN and the physician. 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. 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. A NPI is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS). Medicare and other payers will reimburse providers for items or services that are reasonable and necessary for a diagnosis or injury or to improve the functioning of a malformed body member.9 Both the medical record and billing claim must describe or indicate why the service was necessary. Advanced Practice Nurses must enroll in the Medicare program to be eligible to receive Medicare payment for covered services provided to Medicare beneficiaries. On occasion, there are services or procedures that are not found in the CPT codebook. Almost 90% of NPs are certified in primary care and 69% actually provide primary care.In 2015, 1,965 medical students chose primary care residencies. Not all payers follow Medicare rules and this includes Medicaid. Has a Master's degree in nursing or a Doctor of Nursing Practice degree. (1977). Information: www.cms.gov/nationalprovidentstand/. The Nurse Practitioner, 44(2), 15-17. doi: 10.1097/01.npr.0000552680.76769.e5, Shay, D. F. (2015). The purpose of the CPT code is to provide a uniform language that accurately describes services rendered. The Nurse Practitioner: The American Journal of Primary Health Care, : 2009 34:1,9. Ask to see the policy (if the APRN has a personal attorney, can he/she review the policy)? (2021). Indirect ReimbursementThe Omnibus Budget Reconciliation Act (OBRA) (1990) further supported NPPs by providing direct reimbursement for care in rural areas and indirect reimbursement for care in nursing homes, at 85% of the physician rate (Sullivan-Marx, 2008). Since the pandemic began, several states have voted to permit permanent full practice authority to NPs. The Balanced Budget Act of 1997 granted NPs the ability to directly bill Medicare for services that they perform. More info. In their 2019 meeting, MedPAC recognized that incident to billing masks the true care provided by NPs and recommended stopping incident to billing. When evaluating the 65% reimbursement, MedPAC looked at the services delivered by CNMs and compared them to those of NPs and PAs. Professional liability (malpractice) insurance can protect the practitioner's family, savings, personal belongings, home, and any other assets of value. There are multiple sources of APRN liability insurance available. However, reimbursement is only provided at 85% of the physician rate. The Balanced Budget Act of 1997 granted NPs the ability to directly bill Medicare for services that they perform. This implies that APNs should know the federal and state laws, rules, and regulations that clearly define their scope of practice and prescriptive authority. 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 is a crucial need to equate the primary care reimbursement for all primary care providers. A private insurer may use fee-for-service or capitation as its model for paying for Part A and Part B services on behalf of its enrolled beneficiaries. 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. Congress has not acted on this recommendation (MedPAC, 2019a). When services furnished to hospital inpatients and outpatients are billed directly, payment is unbundled and made to the APRN. 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. Obtained Medicare billing privileges as a NP for the first time before January 1, 2003 and meets the certification requirements described above, or. Reimbursement for Nurse Practitioner Services Position Statement. Documentation of the service must conform to the payer's requirements for the procedure code billed. The salary of the APRN must be unbundled from the hospital's cost report. NPs also have more independent roles as they now lead nurse-managed health centers and retail clinics. Additional and more rigorous research is needed. 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. In addition to the 23 states plus the District of Columbia that previously granted full practice authority for NPs (AANP, 2021), 19 states temporarily removed some, if not all, practice restrictions in May 2020. Evaluation and Management Services Part B. These providers were able to fill the physician void in many communities (Nickerson, 2014). MedPAC estimates a savings of $50 million to $250 million in the first year. Now is the time for NPs to receive full reimbursement from Medicare. Reimbursement for Nurse Practitioner Services Reimbursement for Nurse Practitioner Services Except for a minority of patients who pay their own medical bills, every encounter between an NP and a patient has a third-party participantthe payer. This becomes even more important if Congress chooses to accept MedPACs recommendation and eliminate incident to billing. 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. 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). M-level Service Desk. The credentialing system is used by various organizations and agencies to ensure that their health care practitioners meet all the necessary requirements and are appropriately qualified. (n.d.). It was determined that there was no justification as to why CNMs should be reimbursed less than NPs or PAs (MedPAC, 2002). Data is temporarily unavailable. During this same time, there was a surge of NPs and PAs. . Reducing COVID-19 burden: could Bacille Calmette-Gurin (BCG) vaccines confer protection? She is currently a DNP candidate at the University of Pennsylvania. Reimbursement parity of nurse practitioners (NPs) and physicians is appropriate now more than ever. She is a member of the Gerontology & Geriatrics Education Editorial Board and a peer reviewer for multiple journals. Kennerly S (2007). This is important because, if billing under the physicians provider number, the NPPs name never appears in the billing records. As the APRN determines his/her practice site preference, he/she will need to investigate levels of minimal 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). Is there an association between post COVID-19 syndrome and cognitive impairment? Service/procedure was performed by more than one provider and/or in more than one location. Recognition of this productivity by both parties is crucial for NPPs to receive parity for equal services. You may be trying to access this site from a secured browser on the server. NPs have demonstrated the ability to provide healthcare in a variety of settings, including rural areas and underserved communities, and to serve vulnerable populations, including older adults and those with low income (See Table 1). NPs should adopt the following practices to ensure their claims are reimbursed appropriately and promptly in order to stay up-to-date on each health plan's claims reimbursement requirements: NPs should know their contractual rights and responsibilities contained in provider contracts with health plans and third party payors. (2019a). (2020). NPs are doing much of the same work as their physician colleagues (Sullivan-Marx, 2008); therefore, they should receive the same reimbursement. At the beginning of each code set, specific guidelines identify items that are necessary for appropriately interpreting and reporting the services and procedures within that set. This fact sheet contains the best interpretation of the APRN reimbursement issues as of the date it was written. 8. Please try again soon. 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.). The Balanced Budget Act (1997) removed location restrictions from NPP reimbursement. Dr. Greenberg is a nurse practitioner faculty consultant on the Institute for Healthcare Improvement’s Age-Friendly Health Systems initiative. Generally, the APRN's services should be billed under the APRN's provider number. . Residents in these communities were often older adults, minorities, and low-income populations traditionally with significant healthcare needs. The same year, 14,400 NPs graduated from primary care programs (Barnes, Aiken, & Villarruel, 2016). The MedPAC was also established by the Balanced Budget Act (1997). Appropriate direct reimbursement for these services, independent of a relationship with a physician, is even more warranted in these types of situations where the rules of incident to billing cannot be followed. The number of states granting full practice authority to NPs is growing.NPs now have prescriptive authority in all 50 states. These are legitimate points. Insurance reimbursement for NPs and other Advanced Practice Nurses is all over the board. There are two versions of the documentation guidelines the 1995 and the 1997 versions. Studies have demonstrated that NPs provide the same quality of care as physicians, yet they do not receive the same reimbursement. It is also necessary to document that the services provided have been accurately reported. Studies have supported this NP care as cost-effective. 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. Conversely, the number of NPs is on the rise. Add on codes describe additional intra-service work associated with the primary procedure and must be performed by the same provider. Retrieved from: https://www.congress.gov/111/plaws/publ148/PLAW-111publ148.pdf, Zolot, J. Recognition of this productivity by both parties is crucial for NPPs to receive parity for equal services. AWV. In this episode of omg OMx, Bruker's science-driven podcast, Kate Stumpo interviews Daniel Hornburg, the VP of Proteomics at Seer, as they discuss the innovative technologies in plasma proteomics. Billing is per encounter, not per specific service. NPs now have full practice authority in 23 states and more states have pending legislation (AANP, 2021). 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. Additionally, a nurse practitioner may be selected as a hospice beneficiary's attending physician, but he/she cannot certify or recertify a terminal illness with a prognosis of six months or less. Primary care physician office visits drop by 18%. For encounters that do not meet incident to criteria, report using the APRN's NPI. Evaluating the association between Mediterranean Diet adherence and type 2 diabetes using nutritional biomarkers. Multiple studies have demonstrated that NPs provide quality care comparable with, if not better than physicians (Kippenbrock et al., 2019). 143. Bischof encourages nurse advocacy groups and researchers to direct future studies to investigate how full practice authority and the removal of practice barriers due to the COVID-19 pandemic have affected the level of care that NPs provide. 2004;18:27A28A. 14. $30,000 in bodily injury liability or death liability to more than one person. The levels of E&M services are based on four types of examinations: problem focused, expanded problem focused, detailed, and comprehensive. The CPT codes are updated annually to include new services and/or procedures and to remove obsolete ones. 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. without a physician on-site, NPPs were unable to receive any reimbursement for their services. The services of residents, nursing students, medical students, physician assistant students and APRN students cannot be billed under an APRN's provider number. Rules for billing are complicated, 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.
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