Any Hospitalist APRNS?

[traumaRUs, MSN, APRN]

Okay so I have now applied for a hospitalist team position at a large (900+ bed) tertiary hospital where I used to work as an RN.

They are hiring 4 APRNs to join a team that already has a number of APRNs. They are offering 4 - 9 hour shifts, rotating days/nights/weekends.

Does anyone else work in this kind of position? Do you like it? Why or why not?

[DizzyJ DHSc PA-C]

I was a hospitalist for 1.5 years and loved it (mostly). I did 3 12's one week and 4 12's alternating weeks. My main hospital was a small community hospital and there would be myself and 2 docs on during the day 7a-7p and one doc at night. We split the patients evenly and saw them at our leisure. Patients are not expecting you at any particular time. So, your day is very flexible with the exception of admins wanting all the discharges out before noon. We would meet for coffee, lunch, and just chill in our on-call room. We would see each other constantly as there was only 5 floors. I would run into specialists all day and be able to have face to face conversations about patients. I would often be done rounding by 1pm and hang for a bit before leaving and would keep answering pages until 7p. Only one of us had to stay until sign out to night shift. Only for the admission did the doc have to see the patient and after that the hospital had no requirement for doc to see patient everyday and I followed the patient independently.

The other hospital with a 1000 bed level one trauma center nightmare. I didn't like it at all. There would be a team of 10-12 people on during the day. I would constantly get paged for patients that were not mine even though we faxed a list to the floors every morning. It was always hard finding the nurse for the patient. I could never find the chart anywhere. This hospital required the doc see the patient every day. So, someone had to follow behind me and see everyone. The hospital was so large and I would never run into anyone in my group. So, felt alone all day. Never ran into specialists consults on my patients. Would have to do a string of nights every few months and I would take all floor calls and the doc would do all admits. This was awful! The floor thinks just because we are in-house that they can call us for everything at anytime even though they either new the information hours ago to get their question answered on day shift or it was something that was non urgent and could wait until morning.

[traumaRUs, MSN, APRN]

Ugh!

This hospital has Epic so charting isn't an issue and I worked at this hospital for 10 years as an ER RN but have been gone 11 years now.

I work very independently now and have no interaction with my peers and rare interaction with physicians - we are VERY independent.

I like the idea of shift work - 36 hours versus the 50+ I often do now.

May I ask what you went into after you finished the hospitalist gig?

[DizzyJ DHSc PA-C]

These hospitals had an EHR system but for some reason 90% of inpatient notes were still hand written. I would often enter my note into EHR but then we still had to print it out and put it into the chart. Made no sense to me.

I left this job, moved to Honolulu, and went back into ER. Wish I didn't do this, but never regret and every decision is a learning experience.

[WKShadowNP, DNP, APRN]

I am loving my job and role. We are a small community hospital of just over 200 beds. My shifts are either 10 hours where I round on patients until lunch then go to ED for admits. Or 12 hours where I'm the point person for admits and consults. My collaborative doc signs off on admits and cosigns everything else for incidence to billing. Supportive team that collaborates. See specialists usually face to face.

[angie16451]

I work in a hospital that we provide hositalist services to our groups patients as well as unattached. We also work at a remote hospital and a surgical center. I work M-F with every 4-6 weekend. We do rotating shifts D/P/N. Love what I do, hate the rotating shifts!

[core0]

WKShadowRN said:

I am loving my job and role. We are a small community hospital of just over 200 beds. My shifts are either 10 hours where I round on patients until lunch then go to ED for admits. Or 12 hours where I'm the point person for admits and consults. My collaborative doc signs off on admits and cosigns everything else for incidence to billing. Supportive team that collaborates. See specialists usually face to face.

Just out of curiosity, you're aware that you can't bill incident to for inpatient work? You can use shared billing but the documentation requirements are much more than a signature.

[WKShadowNP, DNP, APRN]

core0 said:

Just out of curiosity, you're aware that you can't bill incident to for inpatient work? You can use shared billing but the documentation requirements are much more than a signature.

I might be using the wrong phrase. Split services are billable and reimbursed. Is that your understanding? The way it was explained to me is that 100% reimbursement occurs this way but only 85% if only I Bill. Isn't that incidence to?

Shared/Split Service | The Hospitalist

[core0]

No incident to is for outpatient encounters where the physician sees the patient for the first encounter and documents it. The PA or NP then sees the patient for additional encounters for that condition. As long as the physician is present in the same suite of offices the encounter can be billed incident to under the physicians NPI at 100%. If the conditions are not present (physician not present, new condition etc) then its billed under the APP at 85%.

In an inpatient setting or a hospital based clinic if the APP sees the patient and documents the encounter, the physician can then see the patient and document on portion of the encounter (HPI, PE or A/P). To meet shared visit the physician has to personally see the patient and has to document one portion of the encounter. Simple signature is not sufficient. It mentions a PA but the rules for NPs are the same.

Personally this doesn't make much sense. It would be better for the physician to see more patients separately then trying to leach an extra 15% off your patients. Just my opinion.

This is from the Florida MAC:

Split-shared visit or "incident to" FAQ

Q. If a physician's assistant (PA) gathers initial information and the physician performs the examination and medical decision making, but the PA dictates the office note, do both the physician and PA need to sign the record for proper documentation?

A. This depends on whether the service is a split/shared visit or if the visit is considered "incident to."

When an evaluation and management (E/M) service is a split/shared encounter between a physician and a non-physician practitioner (NPP), the service is considered to have been performed incident to the physician if the requirements for "incident to" are met and the patient is an established patient. If "incident to" requirements are not met for the split/shared E/M service, the service must be billed under the NPP's national provider identifier (NPI).

A split/shared E/M visit is defined by Medicare as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, examination or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer.

If the physician's signature is the only signature on the visit, Medicare assumes that he/she is indicating they personally performed the visit. Notes recorded in the patient's medical records by another provider are considered relevant documentation of the encounter. Documentation may be dictated and typed or hand-written, or computer-generated and typed or handwritten. Documentation must be dated and include a legible signature or identity.

[WKShadowNP, DNP, APRN]

So Inpatient services can be billed for split/shared services. But not critical care or procedures.

[core0]

WKShadowRN said:

So Inpatient services can be billed for split/shared services. But not critical care or procedures.

Correct. Also you can bill shared services in a hospital based outpatient clinic.

[ghillbert, MSN, NP]

WKShadowRN said:

I am loving my job and role. We are a small community hospital of just over 200 beds. My shifts are either 10 hours where I round on patients until lunch then go to ED for admits. Or 12 hours where I'm the point person for admits and consults. My collaborative doc signs off on admits and cosigns everything else for incidence to billing. Supportive team that collaborates. See specialists usually face to face.

Is the collaborating physician actually seeing all the patients as well as you seeing them? Or just signing notes and billing?