Dumb question--What do you NPs do? - page 3

My program attracts a lot of people interested in becoming NPs. I'm looking more towards the CNS role, as I'm looking for something more hospital-oriented and specialized. I've never wanted to do... Read More

  1. by   sailornurse
    I highly doubt you will ever find an FNP doing a herniorapphy or C-Section, a colonoscopy, or EGD. Probably won't find them putting in chest tubes either. I just dont understand it.. Why is there a need to be an "independent" primary care provider or is it a want to be able to do whatever you want whether you were trained to do it or not?

    WELL since you went out on a limb to search for a listing of "Surgeries" that some UNM Fam practice docs have an option to gain the education, I will point out that the question was about "procedures" that is bedside procedures, performed by primary care providers which FNP's are,not surgeries that nurse do not perform, I do not know what the role of RN's that are surgical first assistants actually is so can not speak to that. Bur Herniorraphy an c=section is major surgery and of course not something nurses do.

    Since you are on the UNM website, you might check out the Acute Care NP program, grads of this program are able to perform a wide variety of bedside procedures. I know one grad from this program and she is able to yes insert chest tubes and central lines. I actually will ask as Family Practice Residents from UNM, we have a handful every year here at Memorial Medical Center, Las Cruces, NM. I will ask them as they come to the ER where I take student nurses, I will ask about the surgical option.
    As to being an independent provider, NP's in New Mexico have independent practice, this means that the board of medicine does not dictate our practice, we do not need a collaborating physician as some states such as Texas require for FNP's. It restricts your practice. In Texas, I can not order cough medicine with codeine as narcotics require physician signature, do you see how this affects ability to prescribe and practice. It does not mean we can perform procedure one is not trained to do. The NM Nurse practice act states you must have the education and certification to perform said procedures. If I wanted to perform for example, IUD insertion I would have to find a mentor, attend workshops etc and get the required training & practice then get certified to do the procedure.
  2. by   caldje
    Quote from sailornurse
    I highly doubt you will ever find an FNP doing a herniorapphy or C-Section, a colonoscopy, or EGD. Probably won't find them putting in chest tubes either. I just dont understand it.. Why is there a need to be an "independent" primary care provider or is it a want to be able to do whatever you want whether you were trained to do it or not?

    WELL since you went out on a limb to search for a listing of "Surgeries" that some UNM Fam practice docs have an option to gain the education, I will point out that the question was about "procedures" that is bedside procedures, performed by primary care providers which FNP's are,not surgeries that nurse do not perform, I do not know what the role of RN's that are surgical first assistants actually is so can not speak to that. Bur Herniorraphy an c=section is major surgery and of course not something nurses do.

    Since you are on the UNM website, you might check out the Acute Care NP program, grads of this program are able to perform a wide variety of bedside procedures. I know one grad from this program and she is able to yes insert chest tubes and central lines. I actually will ask as Family Practice Residents from UNM, we have a handful every year here at Memorial Medical Center, Las Cruces, NM. I will ask them as they come to the ER where I take student nurses, I will ask about the surgical option.
    As to being an independent provider, NP's in New Mexico have independent practice, this means that the board of medicine does not dictate our practice, we do not need a collaborating physician as some states such as Texas require for FNP's. It restricts your practice. In Texas, I can not order cough medicine with codeine as narcotics require physician signature, do you see how this affects ability to prescribe and practice. It does not mean we can perform procedure one is not trained to do. The NM Nurse practice act states you must have the education and certification to perform said procedures. If I wanted to perform for example, IUD insertion I would have to find a mentor, attend workshops etc and get the required training & practice then get certified to do the procedure.
    I made the point to say FNP, not ACNP. Do ACNP's practice hospitalist medicine and insert chest tubes without a physician involved too? DO FNP's get third part reimbursment for their services without a physician involved?

    In regards to bedside procedures, I dont understand what you are talking about. There are very few procedures in family practice that an MA can't do, let alone an RN, FNP, PA, etc. If the shots, and phlebotomy was what you were talking about, then sure, FNPs can do all of that under their nursing license even. BUT, if you were making the statement you seemed to be making, that there is nothing an FP doc can do in NM that an FNP can't do... then I would have to respectfully disagree based on the information above.

    I used the rural FP residency as an example because we need to compare similar things. NM is mostly rural, rural MDs do a lot more than suburban FP MDs as do rural NPs/PAs.
  3. by   patrick1rn
    Quote from core0
    Umm what you are quoting is exactly what I stated. The direct billing refers to the fact that NPs can directly bill for services provided. They are reimbursed at 85% of the physician fee. This did not change incident to billing which requires the physician to see the patient first for any problem and allows the NP to bill for services under the physicians NPI at 100% if the physician is physically present in the clinic when the patient is seen. In the hospital setting the NP can bill for the encounter at 85% or can co bill with the physician under the physicians NPI if the physician document participation in one portion of the encounter. Most NPs do not bill directly but assign the billing to the practice that employs them. To encapsulate there are three ways to bill if you are an NP:
    1. directly at 85%
    2. incident to at 100%
    3. Cobilling 100%



    David Carpenter, PA-C

    Hello Dave, Can medical assistants bill patients also ?
  4. by   sirI
    David is a Physician Assistant, not an un-licensed medical assistant, patrick1rn. So, yes, he does bill patients as well.
    permalink
    Last edit by sirI on Oct 20, '07
  5. by   gauge14iv
    "In Texas, I can not order cough medicine with codeine as narcotics require physician signature, do you see how this affects ability to prescribe and practice."

    Not true - we can prescribe narcotics except for schedule II in Texas. We just need a state TDPS number and our own DEA number as well as a collaborative agreement that allows for same. Doc does not have to sign our narc Rx's however.
  6. by   jbhaktidog
    Quote from sailornurse
    I have not made any such claim. If I had you would have quoted me. I do not equate my education with that of physicians. I never claimed to be equal to an MD either. I simply replied to the question about procedures that an NP could/could not perform, which I interpreted to mean bedside procedures. My understanding is that NP's are educated following nursing models of practice, vs. the medical models.

    Since some basic nursing programs are lacking in basic biological sciences (organic chemistry, genetics to name 2) I agree with you that medical school is definitely more rigid.
    hello All,
    interesting discussion here.
    As a FNP, I have 9 years of university education including organic & inorganic chemistry, several genetics classes, virology under one of the forefront researchers in oncoviruses at the time (no textbook for the class just his lectures), calculus, and way too much more ......
    plus 2 years of internship/clinicals. I received a Masters of Science in Nursing and a Family Nurse Practitioner degree, and have completed some work toward my Doctorate which will be required of all of us by 2015.
    Some of my NP colleagues are assisting surgery in OR, including finishing the surgeries so that the primary surgeon can go on to the next surgery....
    and so many more special skills that listing them becomes redundant since people have already mentioned some of the practices in this forum and this thread.
    I hope that helps to clarify the diversity and possibility of not only Nurse Practitioners but also the level of education required....
    thanks for the discussion,
    jdog
  7. by   JDCitizen
    One shouldn't confuse minimal requirements as applying to everyone.

    I myself have taken more classes than are required for most premed students (Biology, Chemistry, Math, English). I have even delved into psychology.. My eduction in emergency medicine now equates to an associates degree (wish it was on paper). After I graduated school I was lucky enough to spend about a month rounding with a cardio/thoracic surgery group I knew. Pay was nothing, there was no documented/credited clinical experience but it was still a learning experience that helped improve my patient care. Almost everyone brings something different to the table. Everthing is not learned in school..So no confusion: I am not a doctor just like a doctor is not a nurse. I thought about it, started training for it but after much reflection and discussion I decided that once a nurse always a nurse and I could help my patients and their families just fine as a nurse. So here I am: A RN with a APRN degree.

    Now what does a nurse practitioner do? Wow: Varies from state to state, practice to practice... I have seen NPs in hospitals, doctors offices, and clinics... Some with little oversight some with oversight that boarders on prohibitive.. I have even met more than few with their own practices.
    Really pays to go to conferences to see whats out there...

    Just like the posters on this sight: Different providers with different views with different jobs from state to state and at times from country to country....
  8. by   sunray12
    Interesting thread. The debate about how much a NP can do vs a MD prompted me to google the definition state code but didn't take the time to research thoroughly as this was just a quickie search out of curiosity. I do know that I've seen several NP's with their own practices. It should be noted that some RN's do have premed backgrounds either because they were science majors or because its easy enough to take up to two years worth of post-bac science such as organic chemistry, biochem, genetics, etc. This is going above the requirements for a basic ADN and some BSN programs but it could simply be a matter of intellectual curiosity. Also some of your better graduate nursing programs do require residencies - I am looking at a program that requires one year, and although this isn't the same as spending 3-4 years as a Medical resident when you take the time to go from MSN to DNP at the same school it seems to me that you might be putting in time just the same.

    And also what are some of the general key distinctions between a DNP and a MD?
  9. by   hospicenp
    Wow. I sense so much hostility on this thread. Everyone's path is different, depending on where they started and what they want to do, what opportunities arise. Here's a synopsis of mine. I am an RN, first. Did 20+ years in critical care learning lots of ways that people die badly. Got interested in ethics and took a certificate course so I could teach. Decided to get my Masters and ended up on a CNS track. At the end of it there were no jobs. By that time I had realized that the opportunities for me were in hospice as an NP, so more school. As a hospice NP, I do the same things my MD colleagues do. I work in an inpatient unit, and I see patients, manage symptoms, write orders, do paracentesis, order infusions, wound care, and when the occasion arises I extubate vent patients. The important distinction is that while I DO everything the MDs do, I don't KNOW everything they know. I consult with my MD colleagues often. The best part is that after so many years of people dying badly under my care, now they die well, and I am in charge of that. I'm not calling the MD and begging for an order, I'm writing it.
  10. by   Dr. Tammy, FNP/GNP-C
    Quote from core0
    3. Cobilling 100%

    David Carpenter, PA-C
    Could you explain cobilling?
  11. by   Dr. Tammy, FNP/GNP-C
    Quote from caldje
    In regards to bedside procedures, I dont understand what you are talking about. There are very few procedures in family practice that an MA can't do, let alone an RN, FNP, PA, etc.
    Please let me know if MA's (presumably medical assistants) may perform these functions, which are listed as procedures for FNP's, to name just a few:
    Abcess incision and drainage
    Local, digital anesthesia
    Cyst removal
    Diaphragm fitting
    Nasal Packing for Epistaxis
    Excision Biopsy
    Foreign body removal
    Incision and drainage of a bartholin cyst
    Ingrown toenail removal
    Norplant insertion
    Pelvic exams
    Prostate massage for specimen collection
    Punch biopsy
    Rectal prolapse reduction
    Shave biopsy
    skin lesion removal
    Suturing
    Topical application of hemostatic agent
    Condylomata acuminata managment
    Ulcer debridement


    Quote from caldje
    If the shots, and phlebotomy was what you were talking about, then sure, FNPs can do all of that under their nursing license even. BUT, if you were making the statement you seemed to be making, that there is nothing an FP doc can do in NM that an FNP can't do... then I would have to respectfully disagree based on the information above.

    I used the rural FP residency as an example because we need to compare similar things. NM is mostly rural, rural MDs do a lot more than suburban FP MDs as do rural NPs/PAs.

    I'm not sure I understand. In the context of procedures within an out patient setting, what are the procedures an FNP may not perform that a physician may perform?
  12. by   core0
    Quote from Tammy79, RN
    Could you explain cobilling?
    Cobilling is short hand for shared visit. Under Medicare guidelines, a shared visit is when both a physician and NPP treat the same patient on the same day in the hospital/office setting. Medicare allows the work of both health care professional to be combined with the service billed at 100% under the supervising physician as long as the physician performs some face-to-face portion of the visit. The physician's involvement must be documented on the patient's chart.

    Be aware that under Medicare's guidelines, shared visits in the office setting must first meet the "incident to" requirement, making the concept of an office-based shared visit nearly a moot point.

    This is paraphrased from the AAPA reimbursement watch.

    In our practice the PA documents all the elements of the inpatient encounter including the assessment and the plan. The physician sees the patient during rounds and discusses the plan of care. Then documents that they discussed the plan of care and writes any additions to the plan in their documentation. We then bill this at the appropriate level under the physician. A consult cannot be a shared visit and must be billed under whomever does the majority of the E/M work.

    This medscape article explains it in a little more detail.
    http://www.medscape.com/viewarticle/536087_3

    David Carpenter, PA-C
  13. by   core0
    Quote from Tammy79, RN
    Please let me know if MA's (presumably medical assistants) may perform these functions, which are listed as procedures for FNP's, to name just a few:
    Abcess incision and drainage
    Local, digital anesthesia
    Cyst removal
    Diaphragm fitting
    Nasal Packing for Epistaxis
    Excision Biopsy
    Foreign body removal
    Incision and drainage of a bartholin cyst
    Ingrown toenail removal
    Norplant insertion
    Pelvic exams
    Prostate massage for specimen collection
    Punch biopsy
    Rectal prolapse reduction
    Shave biopsy
    skin lesion removal
    Suturing
    Topical application of hemostatic agent
    Condylomata acuminata managment
    Ulcer debridement
    In theory all of these procedures could be done by any unlicensed person under the supervision of the physician. Most state medical practice acts give a physician wide latitude in delegating medical acts. The constraints are usually radiation. The limiting factor on this is usually patient satisfaction, liability and the biggest reason - reimbursement.

    Quote from Tammy79, RN
    I'm not sure I understand. In the context of procedures within an out patient setting, what are the procedures an FNP may not perform that a physician may perform?
    This is going to depend on your state BON and practice environment. For example in Texas an FNP would probably not be allowed to do colposcopy since this is in the domain of the WHNP or CNM. An FP physician could do this. In the outpatient setting especially any physician, essentially has an unlimited license to practice medicine and surgery. An NP will be limited by their training and certification as defined by the BON.

    David Carpenter, PA-C

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