Admitting Privileges for NP's

Trauma Columnist · Nov 4, 2011

CMS requires that an MD be assigned to care for the pt:

https://allnurses.com/nurse-practitioners-np/can-nps-admit-365347.html

TX RN · Nov 4, 2011

NP's have admitting privileges. However, as Trauma has pointed out, federal law under CMS guidelines dictates that ALL hospitalized be under the care of a physician.

It doesn't mean NP's can't round on their own patients, but it does mean that you must assign a physician as the primary.

The credentialing process at facilities is pretty standard. Contact the credentialing department at the facilities your' seeking privileges at and they can tell you what you need to have submitted.

nomadcrna, DNP, CRNA, NP · Nov 13, 2011

It is much more complicated that just saying you must have patients under the care of a physician. The CMS rules are for PAYMENT only. They do not dictate our practice.

I admit medicare patients all the time and am their only provider for their inpatient stay. You can meet any collaboration issues in many ways. To get a license in Alaska, you must place a letter in your file dictating how you will handle referrals and consults to other specialists. You do not have to have formal collaboration agreements or even mention names.

https://www.cms.gov/MLNProducts/downloads/Medicare_Information_for_APNs_and_PAs_Booklet_ICN901623.pdf

4Collaboration occurs when NPs or CNSs:

• Work with one or more physicians to deliver health care services within the scope of their professional

expertise; and

• Medical direction and appropriate supervision is provided as required by the law of the State in which the

services are furnished (it is not required for the collaborating physician to be present when services are

furnished or to independently evaluate patients).

So I met the requirements by "working with specialist" I refer to AND my state does NOT require supervision or collaboration.

See this article and note:

Physician presence at the bottom. Medicare defers to state law.

http://www.aanp.org/NR/rdonlyres/09905D4C-E768-4FB7-9B29-D299EBDF5CA8/0/MedicareReimbursementFactsheet.pdf

http://www.aanp.org/AANPCMS2/LegislationPractice/Practice/Billing/

http://www.aafp.org/fpm/1998/1000/p34.html

http://www.medscape.com/viewarticle/705683_2

Independent Billing

Since 1998, designated NPPs are allowed to submit Medicare Part B claims for services, including procedures, provided in any inpatient or outpatient setting. For billing purposes, these “independent” services do not require physician involvement (e.g. physician initiation of care plan, physician-patient encounter, or physician presence on patient floor/unit) unless otherwise specified by state legislation or facility standards of practice. NPPs do not need to be employed by the physician group. The entity employing the physician group also may employ the NPP.

Claim requirements mandate the use of a national provider identifier (NPI) on all claims, therefore, all NPPs receive an NPI for claim submission. However, not all NPPs may directly bill Medicare or receive direct payment (e.g., physician assistant).1 In this situation, the NPP employer (i.e., physician or group), reports the service with the physician or group provider number and the NPP’s NPI included for identification of who actually provided the service.

Medicare Part B processes NPP claims reported under the independent billing option. Duplicate payments from any other Medicare Part A or Part B source is strictly prohibited and may result in refunds, fines and penalties. Generally, Medicare payment for NPP services is limited to 85% of the allowable physician rate. Financial impact of the 15% rate reduction is typically offset by the increase in physician time. Physicians may use this time to provide more comprehensive or complex services (admissions or consultations), potentially generating more revenue. Consistent with all provider documentation, NPP documentation must support the reported service.

TX RN · Nov 14, 2011

It is much more complicated that just saying you must have patients under the care of a physician. The CMS rules are for PAYMENT only. They do not dictate our practice.
I admit medicare patients all the time and am their only provider for their inpatient stay. You can meet any collaboration issues in many ways. To get a license in Alaska, you must place a letter in your file dictating how you will handle referrals and consults to other specialists. You do not have to have formal collaboration agreements or even mention names.
https://www.cms.gov/MLNProducts/downloads/Medicare_Information_for_APNs_and_PAs_Booklet_ICN901623.pdf
4Collaboration occurs when NPs or CNSs:
* Work with one or more physicians to deliver health care services within the scope of their professional
expertise; and
* Medical direction and appropriate supervision is provided as required by the law of the State in which the
services are furnished (it is not required for the collaborating physician to be present when services are
furnished or to independently evaluate patients).
So I met the requirements by "working with specialist" I refer to AND my state does NOT require supervision or collaboration.

"NPs are not free to take over the care of hospitalized patients on their own, however, even in permissive states like Oregon. A physician must be involved in the process of care for hospitalized patients, because, under federal law governing hospitals, a hospital must require that 'every patient be under the care of a physician.'"

http://www.medscape.com/viewarticle/422935_6

Advanced Practice Columnist / Guide · Nov 14, 2011

This is a reply from CMS taken from an inquiry at another forum for ACNP's:

CMS requires that Medicare patients must be "under the care of a doctor of

medicine or osteopathy." (482.12©(2)) CMS 482.12©(4) states: A doctor of

medicine or osteopathy is responsible for the care of each Medicare patient with

respect to any medical or psychiatric problem that (1) is present on admission

or develops during hospitalization....

Interpretive Guidelines state: "CMS hospital regs do permit doctors of dental

surgery, dental medicine, podiatric medicine, or optometry; chiropractors or a

clinical psychologists) as allowed by State law, to admit patients to a

hospital." However, patients must be under the care of an MD/DO for any medical

or psychiatric problem outside the scope of practice of admitting practitioners.

Survey procedures state: "If non-MD/DOs admit patients, verify that every

Medicare/Medicaid patient is being monitored by an MD/DO who is responsible for

any medical or psychiatric problem outside the scope of practice of admitting

practitioners." However, in view of Interpretive Guidelines, I think the

non-MD/DOs are limited to doctors of dental surgery and the like listed above.

DHS regulations require that Medical Staff bylaws contain a process to assure

that "each inpatient has an attending physician." (R9-10-207.A.7.f) The

regulations define an "attending physician" as "a physician with clinical

privileges who is accountable for the management of medical services delivered

to a patient."

This is from a CMS memorandum: https://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter05-42.pdf

nomadcrna, DNP, CRNA, NP · Nov 14, 2011

Of course this came from an author of an article, not actual regs as Juan posted. I'm not saying its true or untrue but where you quoted it from would be nice. :)

The below is a link from CMS date 2011. I'm not sure if it supersedes what Juan posted or what.

https://www.cms.gov/MLNProducts/downloads/Medicare_Information_for_APNs_and_PAs_Booklet_ICN901623.pdf

I'll have to check with the billers. Again, this is for payment only, not practice. Maybe they eat the medicare charges, I'm not sure.

"NPs are not free to take over the care of hospitalized patients on their own, however, even in permissive states like Oregon. A physician must be involved in the process of care for hospitalized patients, because, under federal law governing hospitals, a hospital must require that 'every patient be under the care of a physician.'"
http://www.medscape.com/viewarticle/422935_6

Advanced Practice Columnist / Guide · Nov 14, 2011

The below is a link from CMS date 2011. I'm not sure if it supersedes what Juan posted or what.
https://www.cms.gov/MLNProducts/downloads/Medicare_Information_for_APNs_and_PAs_Booklet_ICN901623.pdf

This link above is about billing. We NPP's (PA's and NP's), have always been allowed to bill in the in-patient setting and NP's in particular, directly bill Medicare. I think the question is whether a nurse practitioner can independently admit a patient to the hospital without any physician involvement. Federal regulations are listed under the letters CFR (Code of Federal Regulations) and per CFR 42, paragraph 482.12©(2), NP's and PA's can admit a patient to a CMS participating hospital as long as there is evidence that the patient is also under the care of a physician (MD/DO). Obviously, there are ways around making sure that the hospital is in compliance. One way is to have something written in the individual hospital's by-laws that a physician oversees the care provided by the NP in the in-patient setting. I'm not saying you are wrong for following your own patients in the hospital from admission to discharge because that is allowed as long as there is also a physician on record that is also in charge of the patient's care.

TX RN · Nov 14, 2011

Of course this came from an author of an article, not actual regs as Juan posted. I'm not saying its true or untrue but where you quoted it from would be nice. :)

Is this question directed at me?

It's a quote from the link provided. :smokin:

And yes, it's pretty clear that it is CMS hospital regulations. Read the article in it's entirety, if you haven't already, it's actually pretty informative. All of the sources are cited at the end, you can find where the CMS regulation is pulled from.

The below is a link from CMS date 2011. I'm not sure if it supersedes what Juan posted or what.
https://www.cms.gov/MLNProducts/downloads/Medicare_Information_for_APNs_and_PAs_Booklet_ICN901623.pdf
I'll have to check with the billers. Again, this is for payment only, not practice. Maybe they eat the medicare charges, I'm not sure.

The OP question seems to be directed as to the regulatory process of admitting patients to hospitals, not the regluatory process of billing inpatients.

Not taking anything away from you or the state in which you practice in, I'm just citing a source with interpretation of a federal statute.

nomadcrna, DNP, CRNA, NP · Nov 14, 2011

Well, the regulatory process of admitting patients and whether you are legally allowed to admit is a function of state law, not federal law.

The conditions of participation is purely for getting paid by medicare. That seems to me, to be a billing function. The feds cannot tell the state how you practice. They can tell you what you need to do to be paid for medicare patients.

I did read the article and that was the authors interpretation of CMS. What he interpreted was not entirely accurate. A NP is this state and many others CAN admit and follow their patients LEGALLY according to state law. If the patient happens to be a medicare patient, they may have issues getting paid for it. The hospital may have issues getting paid for it.

http://www.cms.gov/manuals/Downloads/som107ap_a_hospitals.pdf

Hospitals are required to be in compliance with the Federal requirements set forth in the Medicare Conditions of Participation (CoP) in order to receive Medicare/Medicaid payment.

nomadcrna, DNP, CRNA, NP · Nov 15, 2011

Here are our bylaws. I typed them out here but I can send you a copy if you need.

For the purpose of these bylaws, the term "medical Staff" shall be interpreted to include all providers who are privileged to attend patients in xxxx medical center, and the term "active" shall be interpreted to include all member providers categorized as Active Medical Staff. A "Licensed Independent Practitioner" is, as defined by the State of Alaska, any clinical practitioner who can practice independently under State of Alaska law to include Medical Doctor, Doctor of Osteopathic Medicine, Nurse practitioner, Certified REgistered Nurse Anesthetist, Certified Nurse Midwife, and Podiatrist.

Allied Health Professional:

Consists of non-phyisician health professionald and license practitioners who providecare to patients at this medical center. The allied staff include4s psychologist, optometrists, and masters of social work, and physical therapists who have been granted limited privileges a this medical center. Physician Assistants will function within their collaborative agreements.

I am currently working on obtaining both admitting privileges as well as membership on medical staff for NP's at the facility I am employeed by. Has anyone had any experience with either. I am in search of policy/bylaws that reflect both. HELP!
JJ

TX RN · Nov 15, 2011

Well, the regulatory process of admitting patients and whether you are legally allowed to admit is a function of state law, not federal law.
The conditions of participation is purely for getting paid by medicare. That seems to me, to be a billing function. The feds cannot tell the state how you practice. They can tell you what you need to do to be paid for medicare patients.
I did read the article and that was the authors interpretation of CMS. What he interpreted was not entirely accurate. A NP is this state and many others CAN admit and follow their patients LEGALLY according to state law.

No one said they can't.

The point in contention is whether a NP can admit without a physician being assigned to the patient as dictated by federal law for the hospital to be in compliance.

If the patient happens to be a medicare patient, they may have issues getting paid for it. The hospital may have issues getting paid for it.
http://www.cms.gov/manuals/Downloads/som107ap_a_hospitals.pdf
Hospitals are required to be in compliance with the Federal requirements set forth in the Medicare Conditions of Participation (CoP) in order to receive Medicare/Medicaid payment.

The hospital bills Medicare Part A -- they're the only party that will have issues getting paid if they don't follow Federal law.

The provider, NP, CRNA, MD, DO, etc bills Medicare Part B --- they won't, as you have pointed out, so long as they follow state law.

I know you know this, just want to clear it up for other readers as your statement seems a bit unclear.

Here are our bylaws. I typed them out here but I can send you a copy if you need.
For the purpose of these bylaws, the term "medical Staff" shall be interpreted to include all providers who are privileged to attend patients in xxxx medical center, and the term "active" shall be interpreted to include all member providers categorized as Active Medical Staff. A "Licensed Independent Practitioner" is, as defined by the State of Alaska, any clinical practitioner who can practice independently under State of Alaska law to include Medical Doctor, Doctor of Osteopathic Medicine, Nurse practitioner, Certified REgistered Nurse Anesthetist, Certified Nurse Midwife, and Podiatrist.

Seems like Alaska is ahead of the curve compared to the other 49. Still, Medicare policies is federal legislation and supersedes state and local laws. Interesting to hear what your hospital is doing.