Inpatient tracking/productivity/billing/supervision

core0 · May 20, 2008

hey guys,
just a question for all you inpatient nps/pas. do you have a mobile-based program to track your inpatients for rounds, billing, etc?
how do you get productivity from inpatients? split the bill with your supervising mds because patients are not admitted to "me?"
one of the hospitals i am rounding in, which i'm the first np, expects my supervising md to sign my progress notes/orders within 24 hours. she says she will wait til they get back to medical records and sign... i talk with her about each patient i round on, each day, despite whether or not she will actually see that patient herself that same day. how do yall manage this with your supervising docs?
thanks!!

we used a computer program that was part of our scheduling system. you put in charges each day for the patient and then the billing department did the charges the next day off the system. in our system the physicians did all the charges since we did not take call at night and they might have to add a +time to a charge later. if i was the only one that saw the patient that day they put in hv2(pa) or hcon4 (pa) and billing knew to bill it under our numbers. all of the consults were charged to us unless the attending did the entire consult. otherwise we used cobilling and i would write the note and then the attending would come by later and do one part of the encounter (usually discuss the plan) document it and sign my note. if they are cobilling without the attending seeing the patient then they are committing insurance fraud.

as far as the signing thing, this is a common problem. you have to see how much of a problem its going to be. take a look at your bylaws. in colorado, the note has to be cosigned within 48 hours by law. however, in the state statue and hospital bylaws its the physicians responsibility to cosign the note, not the pa (or np). my docs were good about doing this but occasionally i would d/c a patient before the doc would see them. the note would end up in medical records to be signed. never was a problem even though technically they were violating state statue.

as the first np i would see how its going to fly, but the doc is an adult. you can't make them sign the note when they are supposed to. if this is going to become a problem for you, i would talk to the doc about it, document it and if its still a problem, kick it upstairs (like your other issues).

at my current job, i round and write the notes. then we sit down and look at the labs and make a plan. the attending signs the notes and adds any comments. then they go see the patient. gotta love surgery. on the other hand the nephrologists round three times a day. i would rather have my wisdom teeth out twice a day.

david carpenter, pa-c

DaisyRN, ACNP · May 20, 2008

thanks david...

and yea, right now... i am going around and seeing patients that she gives me to see. the hospital does not call me directly, that way she can sort of "screen" the people they call us on, because she is the only cardiologist in town and frequently gets inappropriate consults (in her opinion). then, every night i check in with her via text and just make sure there arent any additional patients to see the next morning. by the time morning rolls around, i go see my list of patients, do the notes including the plan, write any orders, and call or text her to update her and make sure that i'm on the right track. then... if she sees the patient like she's suppose to, she adds any comments to my notes and signs.

at the other hospital, when i'm with the medical director, i do the same thing, except we go back and round together (time permitting) and he walks me through anything i missed or alternate suggestions. very good, educationally. plus, he signs every chart in a timely manner that way.

and unfortunately, i have already taken her lack of timely signing/rounding upstairs... after reminding her 4 separate times, with proof of documentation i have kept. she just says, "oh i'll sign when it gets to medical records." i will check the bylaws... but the credentialing committee director specifically said, "if we feel like she's not seeing her patients, and she's just relying on you to do the work, and if she's not signing your charts in a timely manner, then we will revoke your privileges." not to hurt me, but it ultimately does... they just have a problem with her. so, that's why i keep reminding her. i dont want my privileges revoked because she's not doing what she's suppose to. my supervisors say that their hands are tied until the ceo decides whether or not they're going to keep her around. and there was a board meeting last tuesday, one she was not invited to, and the partners talked about her... but i don't know what was said.

as for the billing and tracking, some of the docs use palm-based software to keep up with everything and then print it out for the billing department. you ever tried any of this? the other docs just use cards and write down the daily level of service, procedures, etc. and turn that into the billing department. i guess i just need to talk to the billing department to see what theyve been told about my billing in the hospital. lord knows i don't want to be doing all of her work... with her taking all the credit.

core0 · May 20, 2008

thanks david...
and yea, right now... i am going around and seeing patients that she gives me to see. the hospital does not call me directly, that way she can sort of "screen" the people they call us on, because she is the only cardiologist in town and frequently gets inappropriate consults (in her opinion). then, every night i check in with her via text and just make sure there arent any additional patients to see the next morning. by the time morning rolls around, i go see my list of patients, do the notes including the plan, write any orders, and call or text her to update her and make sure that i'm on the right track. then... if she sees the patient like she's suppose to, she adds any comments to my notes and signs.
at the other hospital, when i'm with the medical director, i do the same thing, except we go back and round together (time permitting) and he walks me through anything i missed or alternate suggestions. very good, educationally. plus, he signs every chart in a timely manner that way.
and unfortunately, i have already taken her lack of timely signing/rounding upstairs... after reminding her 4 separate times, with proof of documentation i have kept. she just says, "oh i'll sign when it gets to medical records." i will check the bylaws... but the credentialing committee director specifically said, "if we feel like she's not seeing her patients, and she's just relying on you to do the work, and if she's not signing your charts in a timely manner, then we will revoke your privileges." not to hurt me, but it ultimately does... they just have a problem with her. so, that's why i keep reminding her. i dont want my privileges revoked because she's not doing what she's suppose to. my supervisors say that their hands are tied until the ceo decides whether or not they're going to keep her around. and there was a board meeting last tuesday, one she was not invited to, and the partners talked about her... but i don't know what was said.
as for the billing and tracking, some of the docs use palm-based software to keep up with everything and then print it out for the billing department. you ever tried any of this? the other docs just use cards and write down the daily level of service, procedures, etc. and turn that into the billing department. i guess i just need to talk to the billing department to see what theyve been told about my billing in the hospital. lord knows i don't want to be doing all of her work... with her taking all the credit.

this is actually a huge problem. you have to disclose if you have had your priviliges suspended every time you apply for new privileges. this is also reportable to the national practitioner data bank. i would talk to your medical director and see if you can have him lean on the hospital to go against her privileges instead of yours. unfortunately this is pretty common in small hospitals.

david carpenter, pa-c

Advanced Practice Columnist / Guide · May 20, 2008

just a question for all you inpatient nps/pas. do you have a mobile-based program to track your inpatients for rounds, billing, etc?

for rounds, we have an internet-based, password-protected patient tracking system through the department of surgery. it is essentially a program that allows providers to enter patient information such as mrn's, histories, surgery done, events, etc. this is updated by the providers (mostly np's, pa's, and residents) each time they work. it can be printed out and is also used for shift sign-outs between providers.

our hospital has an entire billing department with enough personnel for one person or coder to be assigned to each unit to track h&p's, consults, procedure notes, critical care notes, daily progress notes, etc. our medical records in the icu are now fully computerized so it's not that hard to track which np or attending are not signing notes. you get an email if you miss a note or did not sign a note. the emails come under the title "revenue opportunity" for mr. so and so or dr. so and so. generally, most of our notes are typically done as a shared-billing as the attending sees the patients as well.

how do you get productivity from inpatients? split the bill with your supervising mds because patients are not admitted to "me?"

we mostly do shared billing. however, sometimes when a procedure was done by an np and an attending was not around to supervise (got called to the or), it gets billed under us. i'm not sure about consults, though, i thought there is a medicare rule that says consults can only be billed under one provider. i have to ask one of the coders about that.

core0 · May 20, 2008

just a question for all you inpatient nps/pas. do you have a mobile-based program to track your inpatients for rounds, billing, etc?
for rounds, we have an internet-based, password-protected patient tracking system through the department of surgery. it is essentially a program that allows providers to enter patient information such as mrn's, histories, surgery done, events, etc. this is updated by the providers (mostly np's, pa's, and residents) each time they work. it can be printed out and is also used for shift sign-outs between providers.
our hospital has an entire billing department with enough personnel for one person or coder to be assigned to each unit to track h&p's, consults, procedure notes, critical care notes, daily progress notes, etc. our medical records in the icu are now fully computerized so it's not that hard to track which np or attending are not signing notes. you get an email if you miss a note or did not sign a note. the emails come under the title "revenue opportunity" for mr. so and so or dr. so and so. generally, most of our notes are typically done as a shared-billing as the attending sees the patients as well.
how do you get productivity from inpatients? split the bill with your supervising mds because patients are not admitted to "me?"
we mostly do shared billing. however, sometimes when a procedure was done by an np and an attending was not around to supervise (got called to the or), it gets billed under us. i'm not sure about consults, though, i thought there is a medicare rule that says consults can only be billed under one provider. i have to ask one of the coders about that.

the shared billing rules do not allow shared billing for consults. this is a relatively recent change in the last three years. i'm not sure about the np front, but the aapa and the ama have been lobbying against this for several years. this is from the sd pa academy. the rules for nps are the same so substitute np where it says pa:

shared visits and billing in a hospital setting

medicare regulations defer to state law with regard to physician supervision requirements in the hospital and reimburse for services provided by pas under medicare part b.

if a service is within a pa's scope of practice as defined by state law and is allowable by the hospital bylaws, a pa may perform and be covered by medicare for that service. to obtain reimbursement for his or her services, the pa should bill medicare using his or her own npi number. billing medicare in this manner will result in the pa being reimbursed at 85 percent of the physician fee schedule rate.

however, it is possible for a pa to be reimbursed at 100 percent of the physician fee schedule for services rendered in a hospital by billing under the physician's name and provider number under the shared bulling guidelines. shared visit billing can be used when the following criteria are met:

1)both the pa and the physician work for the same entity (i.e., same practice, same hospital, etc.).

2)the service performed was an evaluation and management (e/m) service and neither a procedure nor a consult.

3)the physician provided some face-to-face portion of the e/m service with the patient. (he or she did not simply review and agree with the pa's description on the patient's chart.)

4)both the pa and the physician see the patient on the same calendar day.if all criteria are met, the pa's services are billable under the supervising physician's medicare number with payment at 100 percent of the fee schedule. if the criteria are not met, the pa can still perform the service; however, the pa's services must be billed to medicare under the pa's own number for reimbursement at 85 percent of the physician fee schedule.

may i bill medicare at 100 percent for a shared consultation in a hospital setting?

no. at the present time, consultations may not be billed as shared services. pas must bill for their role in consultation services under their own provider number for 85 percent reimbursement. the medical community is joining the aapa in fighting this policy and advocating for the ability to provide shared consultation services.

a number of state medicaid programs are intensively auditing consults. i got this from arkansas medicaid:

http://www.arkmedicare.com/provider/viewarticle.aspx?articleid=5778

issue # 5: service not provided

three services were denied because the service was not provided.

in two cases, the adr was returned with a note "this was billed in error - please disregard claim. therefore, no records to submit."

in one record, both the written consultation note and dictated surgical consultation were signed by an anp and the billing physician, but guidelines for neither incident to nor split-shared billing were met. it could not be determined what portion of the service, if any, was performed by the billing provider. incident to billing is not allowed in the inpatient setting and split-shared billing is not allowed for consultation services.

bottom line, shared billing is a good way to increase revenue if done correctly. it doesn't apply to consults.

david carpenter, pa-c

DaisyRN, ACNP · May 23, 2008

(i posted this in the wrong board.... *hehe*)

i verified the by-laws and nowhere does it say she has to sign behind me in 24 hours. i think it was just an indirect threat by the credentialing director to my supervising doc to make sure she's doing her job. (which no one can make her do!) so, my privileges cannot be revoked... unless she doesn't sign behind me within 30 days. i guess i'll just have to go check the chart room for my charts every week... *moans and groans* and make sure she is signing them. if she's not, then the director said it'd be a good idea for me to approach the director of credentialing committee to voluntarily relinquish my privileges, instead of giving them a chance to revoke them. but he was going to remind the troublemaker about my charts and push her to sign them in a timely manner, as well as talk to her about other things... and neither me or the medical director want it to get to the point where i have to relinquish my privileges.

and i'm learning sooooo much about billing here lately... i made some hospital cards to take with me to keep track of the level of the visits, etc. and i am labeling each day as "shared" or just me... because my doc does not always see the pts, but if she does... she does a note so i mark it as a shared visit on my card. our clinic's billing dept does all of the hospital billing for us. so, i've been visiting with them this week... very helpful. and they've recently been trained on midlevel billing, etc.

allnurses Guide · May 23, 2008

I've also learned a bit about billing reading your posts, so thanks!