Can nurses suture?

[amanda sue]

Under their legal scope of practice, can any nurses suture? LPNs, RNs, NPs, etc? Or is suturing only "allowed" by doctors and physician assitants. I ask because you often hear about military corpsmen and medics suturing (they are taught this during their intial training), but never nurses!

Thanks to all in advance.

[jer_sd]

Unless you are in an urgent care and it is billed incident to the physician or provider (NP or PA).

Jeremy

The real issue is reimbursement in my opinion. The NP or PA is going to get reimbursed. Most others will not.

David Carpenter, PA-C

[amanda sue]

Thanks, everyone!

I was always curious about how that worked...and now I know!

[core0]

Unless you are in an urgent care and it is billed incident to the physician or provider (NP or PA).

Jeremy

I'm confused. Not sure this is on track, but are you saying that a nurse can bill incident to for suturing? You really can't bill incident to for suturing anyway since the Physician needs to do the initial encounter to bill that way for NPP's. You could bill for an OV1 nurse visit but that won't even cover your material costs.

David Carpenter, PA-C

[brissie]

I work in a NICU in Washington State. Our advanced skills nurses can suture after they place UACs and UVCs, also with PICC placements.

[jer_sd]

Patient show up to urgent care with a simple laceration. PA-C needs to see 5 patients an hour, looks at the wound, orders the RN to suture the wound and the suturing is billed incident to the PA freeing the PA to see three more URI or medication refill patients in the same time frame. Just as if you deligate prefomance of an EKG to someone you still bill for it even if you don't do the EKG.

Personaly I would never deligate this since I like suturing, and it has more risk than other procedures such as EKG or splinting. But if state law allows it it could be done and billed for as long as a provider was seeing the patient and orders it to be done.

Jeremy

I'm confused. Not sure this is on track, but are you saying that a nurse can bill incident to for suturing? You really can't bill incident to for suturing anyway since the Physician needs to do the initial encounter to bill that way for NPP's. You could bill for an OV1 nurse visit but that won't even cover your material costs.

David Carpenter, PA-C

[gauge14iv, MSN, APRN, NP]

Yup - NP's in Texas can definately suture - among other things.

[teeituptom, BSN, RN]

I was suturing long before a lot of these doctors I work with were even born. As a Corpsman back 68 to 72

[KellNY, RN]

CNMs can suture. All the NPs I've worked with (urgent care/family med) have sutured. As an RN, I would never suture-I wasn't trained to and feel it would be incredibly selfish to do that to a Pt. Not to mention insurence fraud billing the procedure to someone else. I don't care who it frees up-this is my license.

[jer_sd]

CNMs can suture. All the NPs I've worked with (urgent care/family med) have sutured. As an RN, I would never suture-I wasn't trained to and feel it would be incredibly selfish to do that to a Pt. Not to mention insurence fraud billing the procedure to someone else. I don't care who it frees up-this is my license.

I don't under stand the insurance fraud comment, was this directed to my previous post of billing incident to the provider?

This happens everytime patient visit a clinic for example they bill for phlebotomy if blood is drawn, even if the provider who is billing does not draw the blood. Same with EKG, PFTs, any technical skill (exceptions to rehab coding) can be deligated to an employee and billed under the provider seeing the patient. Now if a RN sees the patient, sutures the patient and the PA/NP/MD does not see the patient, establish a plan of care ect then that would be insurance fraud. Once the plan of care is established further outpatient visits one by the employee do not require the provider to see the patient.

Jeremy

[core0]

I don't under stand the insurance fraud comment, was this directed to my previous post of billing incident to the provider?

This happens everytime patient visit a clinic for example they bill for phlebotomy if blood is drawn, even if the provider who is billing does not draw the blood. Same with EKG, PFTs, any technical skill (exceptions to rehab coding) can be deligated to an employee and billed under the provider seeing the patient. Now if a RN sees the patient, sutures the patient and the PA/NP/MD does not see the patient, establish a plan of care ect then that would be insurance fraud. Once the plan of care is established further outpatient visits one by the employee do not require the provider to see the patient.

Jeremy

If i read the incident to rules they only apply to NPP's. For medicare rules this is NP, CNM, PA and CNS. So if you have an RN do the procedure and bill incident to then that is not within the rules. Secondly the rule applies to the relationship between the Physician and the NPP. NPP's cannot delegate to other personell and bill incident to.

Finally the Carrier's Manual states that "such a service [without physician involvement] ... could be considered to be incident-to when furnished during a course of treatment where the physician performs an initial service and subsequent services of a frequency which reflect his/her active participation in management of the course of treatment." So the physician must preform the initial service and then the NPP can follow up for the same problem. So if you wanted to have the Physician see the patient and suture then have the NPP follow up the wound care that would be incident to. The physician must preform the substantial bulk of the initial service.

This is a pretty good article on incident to:

http://www.aafp.org/fpm/20011100/23thei.html

Bottom line. From my perspective, a PA that sees the patient and then has someone else preform the service then bills incident to is committing insurance fraud. The reimbursment for a Lac is actually pretty good. The reason that ER's use NPP's for lacerations is that you get even more money for critical care time. You have to remember if you are billing for a procedure you need to do it. You have to look at the difference between services and technical components. An EKG is a technical component. The facility bills for the actual EKG and then you bill for the service which is interpreting the EKG. An EKG or venipuncture is not a billable service. On the other hand a laceration repair is. You don't have to do the whole service, for example you could have an MA do the wound irrigation or the dressing. But the actual repair has been done by the person who is billing. There will usually be a technical component There are CPT codes that dictate who can bill for a procedure.

If you see the patient you should also bill for the encounter. For example urgent care - patient comes in with a laceration. You see the patient, take a history, preform a focused physical exam, and initiate a plan. You have the MA clean the wound. You then preform a simple laceration repair. I would bill this as a 99201 Problem focused history, problem focused exam, straight forward medical decision making. I would also bill for a procedure 12001 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less. I would tie the procedure to the visit and the appropriate ICD-9 codes.

Now lets say you have an establised patient that falls out of a tree and and sustains a head lac. This represents a more complex patient. In this case you not only have to do a more detailed history but a detailed exam with more complex medical decision making. I would code this a 99214 detailed exam, detailed history and moderated medical decision making. If he had a 10 cm complex laceration you would put a different procedure code (I think this would be a 13004). In addition some procedures are bundled into the encounter code. For example some E/M codes have EKG interpretation bundled into them.

David Carpenter, PA-C

[jer_sd]

i am not a billing expert by any means, i routinly get remined from my billing department that i under code visits. i used termonology of incident to since the general concept is understood but it also does allow for deligation from npp to staff asd well as from physicain to npp.

however according to medicare mas and rns are considered auxiliary personnel that can provide services under teh direction of a physician or npp. here is clarification form the cms web site q and a section

feedback how should the ordering and supervising providers be indicated when completing the cms-1500 when the service is provided incident to the service of a physician or non-physician practitioner?

answer cms issued cr 3138 to clarify and standardize the method of indicating the ordering and supervising professionals on the cms-1500 when the service is provided incident to the service of a physician or non-physician practitioner . this instruction incorporates the rule from the preamble of the proposed rule for the medicare physician fee schedule on november 1, 2001 (66 fed reg. 55267) into the cms claims processing manual that stated "the billing number of the ordering physician (or other practitioner) should not be used if that person did not directly supervise the auxiliary personnel." the update to the medicare claims processing manual located at the link below further clarifies where physician's provider information numbers and names should be reported when both an ordering provider and a supervising provider are involved in a service provided incident to a physician or non-physician practitioner . however, please note that the cms-1500 paper form is superseded by hipaa electronic formats.

reference: http://www.cms.hhs.gov/manuals

reference: http://www.cms.hhs.gov/mlnmattersarticles/downloads/mm3138.pdf

my interpretation of this is as long as the staff is working within legal guidlines for the state and under supervision of a provider the services are eligable to billed under the providers number. am i off base on my understanding here?

[Ophelia78]

My husband was an offshore medic years ago and had to suture, along with insert foleys if needed (never ended up doing that, to his great relief). Aren't CNM's allowed to suture tears post-birth?