Can NPs admit?

Trauma Columnist · Jan 26, 2009

Depends on your hospital's credentialling. I'm credentialled at six hospitals. At one, I can write "admit to Dr Joe Blow" and sign "traumarus, APN." At another hospital, ALL my orders must be signed "traumarus, APN/Joe Blow, MD".

So...at least for me, its not a billing issue but rather a credentialling issue.

core0 · Jan 26, 2009

I cover for a busy clinic practice every 5th weekend or so. This is part of my "on call" schedule with my employer. Anyway, I have been sent to the ER to evaluate pts and have gotten calls re: patients in the ER. I have given admitting orders for many, many patients. My billing person now thinks that NPs cannot not admit to the hospital and asked the medical credentialling person if I have admiting credentials. She was told that I do not. My boss seems to think the billing specialist is mistaken. I am unsure if this is a hospital policy or a CMS rule. My question is simply, Can an NP admit a patient to the hospital or would he/she have to write the order as a "verbal" order from the dr? Thanks

Medicare specifically lists NPs, CNS, PAs and Physicians as the four providers that can determine whether a patient meets inpatient or observation status. They are also the four types of providers that can bill for the initial inpatient evaluation. So this is not a CMS issue. All inpatients must have an assigned physician per CMS guidelines.

Individual hospitals can restrict admission privileges to MDs only, but this is rare in my experience.

They may be confusing the shared billing rules. Shared billing for initial inpatient evaluation or consults is no longer allowed and must be billed under the provider that does all the work.

Admissions is one of the check boxes on our priviliging sheets. However, the hospital will only give you privileges if you are on an admitting service. For example the NPs in Radiology do not have admitting priveleges. On the other hand since I admit 10-15 patients per week its a good thing that I do.

Check with your hospital medical staff and see if you have priveleges. If you don't see what you need to do to obtain them.

David Carpenter, PA-C

Advanced Practice Columnist / Guide · Jan 26, 2009

Agree with above, you need to be credentialed by the hospital's Credentialing amd Priviledging Committee or Board to perform tasks such as writing admitting orders. In some cases, how you write your orders is very much dependent on stipulations set forth by specific hospitals. JCAHO has actually been checking in on credentialing documents during site visits to hospitals. It is not wise for hospitals to allow midlevels to start working on their own without having gone through credentialing.

As far as billing, Medicare allows a nurse practitioner to write admitting orders if performed in collaboration with a physician. Even in states where the Nurse Practice Act allows for fully-independent practice for nurse practitioners, a collaborating physician on record is still required for a nurse practitioner to directly bill. As David stated, CMS requires that all patients admitted to a hospital be under the care of a physician.

Here is a FAQ from the Amer. Coll. of NP's website: http://www.acnpweb.org/i4a/pages/Index.cfm?pageID=3438

JEKA · Jan 26, 2009

WOW, you guys are fantastic and this site is awesome.

Thank you all so much

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.