Collaborative Care Collaborative Care ModelsModels

Pennsylvania ChapterPennsylvania ChapterAmerican College of CardiologyAmerican College of Cardiology

April 28, 2006April 28, 2006

Michelle Ashby, CRNPMichelle Ashby, CRNPPaul Casale, MDPaul Casale, MDThe Heart GroupThe Heart Group

Lancaster, PALancaster, PA

Objectives:Objectives:

1. Describe several practice models for cardiology utilizing nurse practitioners and physician assistants.

2. Identify 4 benefits of utilizing NPs and/or PAs in a cardiology practice. 

3. Briefly discuss 3 methods to bill for NP and PA services. 

Employment ModelsEmployment Models

• Private PracticePrivate Practice

• University/HospitalUniversity/Hospital

• ““Lease Agreements”Lease Agreements”

OfficeOffice• ““Risk factor” clinicsRisk factor” clinics• Heart failure clinicHeart failure clinic• EP clinicEP clinic• Anticoagulation clinicAnticoagulation clinic• Post-discharge visitsPost-discharge visits• Stress testsStress tests

• Independent schedulesIndependent schedules• ““Tag Team” approachTag Team” approach

HospitalHospital

• AdmissionsAdmissions• ConsultsConsults• RoundsRounds• Nursing callsNursing calls• ProceduresProcedures• On Call coverageOn Call coverage

Supervision of Diagnostic Supervision of Diagnostic TestsTests

• NP/PA may perform diagnostic tests, but may not supervise someone else (tech/nurse) performing the diagnostic test

• "Limited License Practitioners: NP, CNS, and PA are not defined as physicians. Therefore, they may not function as supervision physician under the diagnostic tests benefit. However, when performing diagnostic tests, they are not required to meet the physician supervision requirements defined here. Instead, they may perform diagnostic tests pursuant to State scope of practice laws and under the applicable State requirements for physician supervision or collaboration.”

www.hgsa.com/professionals/refman/appendix-l-m.html

Supervision of Diagnostic Supervision of Diagnostic TestsTests

• General supervisionGeneral supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician. (Level 1)

Supervision of Diagnostic Supervision of Diagnostic TestsTests

• Direct supervisionDirect supervision inin the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. (Level 2)

• Personal supervision means a physician must be in attendance in the room during the performance of the procedure. (Level 3)

“ “ Incident to”Incident to” Billing another providers service using

the physician’s billing number at 100% reimbursement.

• Applies to office setting, not hospital• Physician must personally perform the

initial service and remain actively involved in the course of treatment

• Physician must be present in the office suite

• Can also bill incident to NP/PA service

“ “ Incident to”Incident to” When does the NP/PA need to bill When does the NP/PA need to bill

directly?directly?

(with NP/PA’s billing number, 85%reimbursement)(with NP/PA’s billing number, 85%reimbursement)

• New patientsNew patients• Established patients with new problemsEstablished patients with new problems• Physician is not physically present in Physician is not physically present in

the office suitethe office suite

www.cms.hhs.gov/MLNMattersArticles/downloads/www.cms.hhs.gov/MLNMattersArticles/downloads/SE0441.pdfSE0441.pdf

www.hgsa.com/newsroom/news09162002.shtmlwww.hgsa.com/newsroom/news09162002.shtml

Shared VisitsShared Visits

• Hospital inpatient, hospital outpatient or emergency department E/M service

• Shared between a physician and an NPP from the same group practice

• Physician provides any face-to-face portion of the E/M encounter with the patient

Shared VisitsShared Visits• Service may be billed under either the

physician's or the non-physician's PIN number 

• If there was no face-to-face encounter between the patient and the physician (e.g., even if the physician participated in the service by only reviewing the patient’s medical record) then the service may only be billed under the non-physician's PIN (at 85%) 

Shared VisitsShared Visits• The service must be within the scope of

practice for the NPP

• The service must be “reasonable and necessary” as defined by Title XVIII of the Social Security Act, Section 1862(a)(1)(A)

• The NPP service and the physician service may occur jointly or at independent times on the same calendar day

Shared VisitsShared Visits• The total documentation by both the

NPP and the physician should support the level of service reported

• Non-physician practitioner (NPP) is a nurse practitioner, clinical nurse specialist, certified nurse midwife, or a physician assistant – however CNS has no scope of practice in Pennsylvania

• NPP sees a hospital inpatient at one time and documents his/her service. 

• Physician, later in the day, has a face-to-face encounter with the patient, personally verifies one (or more) element(s) of the NPP encounter, and documents his/her participation in the medical record. 

• Either the physician or NPP may report the service based on the combined documentation.

Documentation of Shared Documentation of Shared VisitsVisits

Documentation of Shared Documentation of Shared VisitsVisits

Acceptable documentation from physician:• “Seen and agree.  Less abdominal pain today. 

Legible physician signature.”  • “Agree with above.  Lungs clear.  Legible

physician signature.”

Unacceptable documentation:  • “Noted.  Proceed with endoscopy.  Legible

physician signature.”  (This documentation fails to establish the face-

to-face encounter by the physician with the patient.)

Shared VisitsShared VisitsFrequently Asked Questions

Q:  Can I apply the shared/split billing rules to medical students?  Residents?  Nurses?  Other personnel in my employ or under my supervision? 

A:  No.  The shared/split billing rules apply only to NPPs. 

Q:  Can a procedure be billed using the shared/split billing rules?

A:  No.  Only evaluation and management services (CPT codes 99201-99399) may be billed using the shared/split billing mechanism.

Shared VisitsShared VisitsFrequently Asked Questions (cont’d)

Q:  Can the NPP and the physician bill for a time-based E/M service based on their pooled time?

A:  Yes.  The NPP and the physician may pool their non-overlapping time for the time-based codes (e.g. discharge day management, CPT 99238-99239).  This, however, does not include critical care services at this time.

Q:  Can the NPP and the physician bill for a shared/split E/M service based on their pooled time dedicated to counseling/coordinating care? 

A:  Yes.  The NPP and the physician may pool their non-overlapping time spent counseling/coordinating care.

Shared VisitsShared VisitsFrequently Asked Questions (cont’d)Frequently Asked Questions (cont’d)

Q:  Does the NPP have to be in my direct employ?A:  No.  For any setting, the NPP may be directly

employed by the physician, physician  group, or entity that employs the physician(s). The NPP services may also be leased by the physician, physician group, or entity that employs the physician(s) or an independent contractor.

Q:  Must the NPP be in my provider group?    A:  Yes.  Regardless of the employment

arrangement (e.g., W-2 employee, leased or independent contractor) between the NPP and the physician, physician group, or entity that employs the physician(s), the NPP’s provider number must be linked to provider group of the physician rendering the shared/split service.

ConsultationsConsultations• Effective 1/1/06 consultations cannot

be billed as a shared/split visit

• The intent of a consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional's knowledge.

• Consultations may be billed based on time if the counseling/coordination of care constitutes more than 50 percent of the face-to-face encounter

http://www.hgsa.com/professionals/lcd/c2h.html

National Provider National Provider Identifier (NPI) Identifier (NPI)

• Health Insurance Portability and Accountability Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the Act of 1996 (HIPAA) mandated that the Secretary of Health and Human Services adopt Secretary of Health and Human Services adopt a standard unique health identifier for health a standard unique health identifier for health care providerscare providers

• NPI remains with the provider regardless of job NPI remains with the provider regardless of job or location changes or location changes

• In use by May 23, 2007, but small health plans In use by May 23, 2007, but small health plans have until May 23, 2008 have until May 23, 2008

• To apply: https://nppes.cms.hhs.gov

MedicaidMedicaid

• Medicaid will now credential all NPs, regardless of Medicaid will now credential all NPs, regardless of specialtyspecialty

• MA Bulletin (12/16/05) MA Bulletin (12/16/05) Clarification of Enrollment Policy for CRNPs Clarification of Enrollment Policy for CRNPs http://www.dpw.state.pa.us/Business/BulletinManahttp://www.dpw.state.pa.us/Business/BulletinManageDir/003673169.aspx?BulletinId=1133geDir/003673169.aspx?BulletinId=1133

Professional ResourcesProfessional Resources• Pennsylvania Coalition of Nurse Pennsylvania Coalition of Nurse

PractitionersPractitioners (PCNP) (PCNP) www.pacnp.org www.pacnp.org • American College of Nurse American College of Nurse

PractitionersPractitioners (ACNP) www.acnpweb.org (ACNP) www.acnpweb.org

• American Academy of Nurse American Academy of Nurse PractitionersPractitioners (AANP) www.aanp.org (AANP) www.aanp.org

• Pennsylvania Society of Physician Pennsylvania Society of Physician AssistantsAssistants (PSPA) www.pspa.net (PSPA) www.pspa.net

• American Academy of Physician American Academy of Physician AssistantsAssistants (AAPA) www.aapa.org (AAPA) www.aapa.org

217 Harrisburg Ave., Suite 200217 Harrisburg Ave., Suite 200Lancaster, PA 17603Lancaster, PA 17603

Michelle Ashby, CRNP Michelle Ashby, CRNPph (717) 390-4676ph (717) 390-4676

ashbynp@comcast.net ashbynp@comcast.net

Paul Casale, MD Paul Casale, MD ph (717) 397-5484ph (717) 397-5484