ICU NP/PA schedules

[ghillbert]

We currently just have 2 ACNPs for a 24-bed cardiothoracic ICU which is very high acuity and busy. We round, do notes and bill on our 6-12 patients, do procedures, allocate patients to any residents/students we have on service, do signout for the night intensivist. We are having trouble getting out on time as posted are still rolling in right when we try to leave.

The second NP just started, prior to that I was working Mon-Thurs 6-4, no holidays or weekends. She accepted the job with the director's agreement to move to 3 day weeks. Now I am trying to work out the best schedule. I don't want us to start covering weekends and holidays without the employer reviewing the pay rate because I accepted the job at the current rate for weekday hours.

What do you do for APPs in your ICUs? Do you do 3x12 and have staff be 0.9 FTE? Or 14/13/13 for 1.0 FTE? What shift times? Do you have a shift differential built into your pay scale? If there are 2 of you there on a shift do you stagger shift hours or both work same time? Did your shifts/schedules change as you added more providers?

Thanks for any help with this!

[ghillbert, MSN, NP]

Your question doesn't completely make sense. A physician cannot bill for APP critical care. Critical care cannot be shared billing and can only be billed to the NPI of the provider who does the work. If the physicians are billing for APP critical care then they are committing fraud.

Sorry for confusion. By this I mean the APP is working in critical care, seeing patients and managing issues during the day. The physicians round, see patients in person and complete exam, discuss as multidisciplinary group, and then physician bills cc. It was very difficult for me to explain why APP care was different than resident/fellow in that they could not attest/addend the cc note by an APP and bill for it. I understand that in billing land, you can't share cc, but in practice the APP doesn't see patients entirely independently in that unit. Since attendings round, examine patient and participate in plan, they feel they should be able to bill. I told them then they have to have APP write a 99233 and bill that and have it attested and billed at 100% by physician, but they can't do it with CC codes.

For non medicare patients, the insurance usually doesn't credential APPs but wants the bill placed under the physician. For those patients our billing software has field for billing provider and rendering provider. All RVUs are credited to the rendering provider. So for critical care I get credit for all the RVUs that I provide whether private payer or Medicare/Caid.

That's nice, I don't think our software has that ability. My billing is just through Epic but admittedly no-one at my hospital has any idea about APP cc billing so it's hard to get answers about anything lol.

For E/M some of our ICUs use shared billing. Remember for shared billing the physician must see the patient and personally document one element of the encounter. Seen and agree doesn't cut it. Some ICUs don't bill on APP patients so the billing is under the APP as above (rendering provider gets credit). For shared billing we have another slot for shared provider. The credit for the RVUs depends on the department. Some are 50/50 others are lower. The lowest is 85/15 (app/physician). This represents the extra money that the institution gets from the shared billing. They are trying to discourage this because its really unproductive work (see the patient talk to them and document for 15% of the bill). Its much more effective to see another patient by themselves.

Makes sense.

Our institution does a good job of tracking productivity. In high production sections the expectation is that the APP brings in at least 125% of salary.

Interesting. I know my RVUs are high bc I see about 12 patients per day. It sounds amazing at some of these bigger systems with more established APP programs and infrastructure. We are interviewing for an APP Director so hopefully my institution gets on board with investigating some of this stuff.

Thanks for your valuable input as always, David. I appreciate your time.

[ghillbert, MSN, NP]

It can be tough to prove our worth without the dollar figures that RVU's reveal but there are other ways that NP's contribute to a specific practice apart from revenue generation. There are many places that put as much emphasis on outcomes as much as profits. It can be convincing to show our worth by measuring the positive impact NP's bring by using quality measures.

Examples of measurable outcomes would be compliance with vent budles, sepsis activation response times, time to extubation (important in cardiac surgery), etc. I know they can be subjective at times and data can be muddied by the fact that most practices are collaborative in nature so it's hard to pinpoint who deserves the credit. However, some attendings can be poor at EMR usage and important order sets tend to not be written correctly sometimes which doesn't help with compliance. That's where we can come in and EMR data is easy to track.

Thanks! I am really trying to pinpoint who is the keeper of the data... it's hard bc the ICU is mixed cardiac surgery, vascular, thoracic, transplant... and all the primary services seem to keep and track their data differently. I don't see a central ICU method of tracking the data or monitoring quality outcomes so I would like to implement such.