Can nurses suture? - page 3

by amanda sue 33,419 Views | 38 Comments

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... Read More


  1. 0
    Quote from KellNY
    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
  2. 0
    Quote from jer_sd
    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
    Last edit by core0 on Mar 30, '07
  3. 0
    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/mlnmattersart...ads/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?
  4. 0
    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?
  5. 0
    Quote from Ophelia78
    Aren't CNM's allowed to suture tears post-birth?
    yep, definitely.
  6. 0
    Quote from 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/mlnmattersart...ads/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?
    well i learned something. i asked a gentleman who is considered the billing guru for pa's. this was his answer:

    pas, nps, rns and other office staff (medical assistant) may provide services “incident to” the physician. in addition, rns, lpns, and medical assistants can provide services “incident to” the pa. if provided “incident to” the physician, then payment is at 100%. if an rn provides services “incident to” the pa then the 85% payment is in effect.

    the key issue is what the rn or lpn may do. their scope of practice under medicare is generally limited to ancillary duties such as blood pressure readings, injections, and similar services. they can not practice medicine. i don’t believe that the rn is covered by medicare for suturing.

    private payers can make up their own rules as to who can do what.

    if a nurse provides a covered service without the involvement of the physician, pa or np, then it is billed at a level 99201 or 99211. generally, the physician, pa or np must be on site for this type of billing to occur.

    looking further i found this: hhs 410.75 which describes medicare billing for the nurse practitioner. notice the bolded part. my interpretation is if there is a cpt attached you need to do it yourself. a physician may delegate this to a npp since they are medicare billers. nurses for example, cannot bill medicare (they do not have a npi). therefore you cannot bill for cpt codes under incident to. there are cpt codes for things like vaccination that nurses can bill for, but if you break out the codes you notice that there are no rvu's attached meaning that medicare is only paying for the technical component (the vaccine and the cost of giving the shot).

    short answer, can nurses suture - sure (within the limits of the state scope of practice). long answer - billing for nurses (not np's or cnm or cns) who suture probably constitutes medicare fraud (other insurance can make whatever rule they want).

    to the other poster on paramedics. offshore platforms exist in a medical never never land depending on if they are in us continental waters or not. this is very similar to cruise ships. there is great latitude on what can and cannot be done. also the only real issue we were discussing is billing. if a paramedic sutures this is legal (as long as it is within any applicable scope of practice). if they bill for it this would be illegal. this is how the army gets away with letting medics suture. there are no applicable scope of practice laws for medics (or its what the army says they are). this is the reason that they would generally not let nurses (lpn or rn) suture when i was in. the nurse may have a license in any number of states (you do not have to have a license in the state the post is in just have a license in the army). with suturing being outside the scope of practice in some states they chose a blanket prohibition (from what i remember).

    david carpenter, pa-c
    hhs 410.75 follows look at the bold section.

    (d) services and supplies incident to a
    nurse practitioners’ services. medicare
    part b covers services and supplies (including
    drugs and biologicals that cannot
    be self-administered) incident to a
    nurse practitioner’s services that meet
    the requirements in paragraph (c) of
    this section. these services and supplies
    are covered only if they—
    (1) would be covered if furnished by a
    physician or as incident to the professional
    services of a physician;
    (2) are of the type that are commonly
    furnished in a physician’s office
    and are either furnished without
    charge or are included in the bill for
    the nurse practitioner’s services;
    (3) although incidental, are an integral
    part of the professional service
    performed by the nurse practitioner;
    and
    (4) are performed under the direct supervision
    of the nurse practitioner
    (that is, the nurse practitioner must be
    physically present and immediately
    available).
    (e) professional services. nurse practitioners
    can be paid for professional
    services only when the services have
    been personally performed by them and
    no facility or other provider charges,
    or is paid, any amount for the furnishing
    of the professional services.
    (1) supervision of other nonphysician
    staff by a nurse practitioner does not
    constitute personal performance of a
    professional service by a nurse practitioner.

    (2) the services are provided on an
    assignment-related basis, and a nurse
    practitioner may not charge a beneficiary
    for a service not payable under
    this provision. if a beneficiary has
    made payment for a service, the nurse
    practitioner must make the appropriate
    refund to the beneficiary.
    [63 fr 58908, nov. 2, 1998; 64 fr 25457, may 12,
    1999, as amended at 64 fr 59440, nov. 2, 1999]
  7. 0
    Quote from KellNY
    yep, definitely.
    CNM's are non physician providers under medicare guidelines for providers and can suture. As far as I know any NPP can suture (and bill for it). The question (as I interpret it) was can RN's (or LPN's) suture. The answer is depends on your state. For the answer on billing for this see my other post.

    David Carpenter, PA-C
  8. 0
    Suturing? No thanks, I have enough to do already.
  9. 0
    I am an offshore medic, currently 45 miles offshore from a third world country. I suture all the time. After I finish nursing school, get my BSN and then my CNOR and RNFA perhaps I can suture onshore also. LOL
  10. 0
    Of course NPs can suture. But for RNs to suture is dangerous. They dont teach that in RN school and 99% of them are not trained to do it. I have NEVER seen a doc let an RN suture anybody in the ED. Its always an NP that does it.


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