Collaborative Care Models Pennsylvania Chapter American College of Cardiology April 28, 2006 Michelle Ashby, CRNP Paul Casale, MD The Heart Group Lancaster, PA

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Collaborative Care ModelsPennsylvania
ChapterAmerican College of CardiologyApril 28,
2006Michelle Ashby, CRNPPaul Casale, MDThe
Heart GroupLancaster, PA
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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. 

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Employment Models

• Private Practice
• University/Hospital
• Lease Agreements

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Office

• Risk factor clinics
• Heart failure clinic
• EP clinic
• Anticoagulation clinic
• Post-discharge visits
• Stress tests
• Independent schedules
• Tag Team approach

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Hospital

• Admissions
• Consults
• Rounds
• Nursing calls
• Procedures
• On Call coverage

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Supervision of Diagnostic Tests

• 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.h
  tml

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Supervision of Diagnostic Tests

• General supervision means the procedure is
  furnished under the physicians overall direction
  and control, but the physicians 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)

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Supervision of Diagnostic Tests

• Direct supervision in 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)

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Incident to

• Billing another providers service using
  the physicians 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

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Incident to

• When does the NP/PA need to bill directly?
• (with NP/PAs billing number,
  85reimbursement)
• New patients
• Established patients with new problems
• Physician is not physically present in the office
  suite
• www.cms.hhs.gov/MLNMattersArticles/downloads/SE044
  1.pdf
• www.hgsa.com/newsroom/news09162002.shtml

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Shared 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

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Shared 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 patients medical record) then the
  service may only be billed under the
  non-physician's PIN (at 85) 

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Shared 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

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Shared 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

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Documentation of Shared Visits

• 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.

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Documentation of Shared Visits

• 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.)

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Shared Visits

• Frequently 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.

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Shared Visits

• Frequently Asked Questions (contd)
• 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.

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Shared Visits

• Frequently Asked Questions (contd)
• 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 NPPs provider
  number must be linked to provider group of the
  physician rendering the shared/split service.

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Consultations

• 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

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National Provider Identifier (NPI)

• Health Insurance Portability and Accountability
  Act of 1996 (HIPAA) mandated that the Secretary
  of Health and Human Services adopt a standard
  unique health identifier for health care
  providers
• NPI remains with the provider regardless of job
  or location changes
• In use by May 23, 2007, but small health plans
  have until May 23, 2008
• To apply https//nppes.cms.hhs.gov

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Medicaid

• Medicaid will now credential all NPs, regardless
  of specialty
• MA Bulletin (12/16/05)
  Clarification of Enrollment
  Policy for CRNPs http//www.dpw.state.pa.us/Busine
  ss/BulletinManageDir/003673169.aspx?BulletinId113
  3

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Professional Resources

• Pennsylvania Coalition of Nurse Practitioners
  (PCNP) www.pacnp.org
• American College of Nurse Practitioners (ACNP)
  www.acnpweb.org
• American Academy of Nurse Practitioners (AANP)
  www.aanp.org
• Pennsylvania Society of Physician Assistants
  (PSPA) www.pspa.net
• American Academy of Physician Assistants (AAPA)
  www.aapa.org

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217 Harrisburg Ave., Suite 200Lancaster, PA
17603 Michelle Ashby, CRNPph (717)
390-4676ashbynp_at_comcast.net Paul Casale, MD
ph [phone]