Dumb question--What do you NPs do?

Dr. Tammy, FNP/GNP-C · Oct 16, 2008

In regards to bedside procedures, I dont understand what you are talking about. There are very few procedures in family practice that an MA can't do, let alone an RN, FNP, PA, etc.

Please let me know if MA's (presumably medical assistants) may perform these functions, which are listed as procedures for FNP's, to name just a few:

Abcess incision and drainage

Local, digital anesthesia

Cyst removal

Diaphragm fitting

Nasal Packing for Epistaxis

Excision Biopsy

Foreign body removal

Incision and drainage of a bartholin cyst

Ingrown toenail removal

Norplant insertion

Pelvic exams

Prostate massage for specimen collection

Punch biopsy

Rectal prolapse reduction

Shave biopsy

skin lesion removal

Suturing

Topical application of hemostatic agent

Condylomata acuminata managment

Ulcer debridement

If the shots, and phlebotomy was what you were talking about, then sure, FNPs can do all of that under their nursing license even. BUT, if you were making the statement you seemed to be making, that there is nothing an FP doc can do in NM that an FNP can't do... then I would have to respectfully disagree based on the information above.
I used the rural FP residency as an example because we need to compare similar things. NM is mostly rural, rural MDs do a lot more than suburban FP MDs as do rural NPs/PAs.

I'm not sure I understand. In the context of procedures within an out patient setting, what are the procedures an FNP may not perform that a physician may perform?

core0 · Oct 16, 2008

Could you explain cobilling?

Cobilling is short hand for shared visit. Under Medicare guidelines, a shared visit is when both a physician and NPP treat the same patient on the same day in the hospital/office setting. Medicare allows the work of both health care professional to be combined with the service billed at 100% under the supervising physician as long as the physician performs some face-to-face portion of the visit. The physician's involvement must be documented on the patient's chart.

Be aware that under Medicare's guidelines, shared visits in the office setting must first meet the "incident to" requirement, making the concept of an office-based shared visit nearly a moot point.

This is paraphrased from the AAPA reimbursement watch.

In our practice the PA documents all the elements of the inpatient encounter including the assessment and the plan. The physician sees the patient during rounds and discusses the plan of care. Then documents that they discussed the plan of care and writes any additions to the plan in their documentation. We then bill this at the appropriate level under the physician. A consult cannot be a shared visit and must be billed under whomever does the majority of the E/M work.

This medscape article explains it in a little more detail.

http://www.medscape.com/viewarticle/536087_3

David Carpenter, PA-C

core0 · Oct 16, 2008

Please let me know if MA's (presumably medical assistants) may perform these functions, which are listed as procedures for FNP's, to name just a few:
Abcess incision and drainage
Local, digital anesthesia
Cyst removal
Diaphragm fitting
Nasal Packing for Epistaxis
Excision Biopsy
Foreign body removal
Incision and drainage of a bartholin cyst
Ingrown toenail removal
Norplant insertion
Pelvic exams
Prostate massage for specimen collection
Punch biopsy
Rectal prolapse reduction
Shave biopsy
skin lesion removal
Suturing
Topical application of hemostatic agent
Condylomata acuminata managment
Ulcer debridement

In theory all of these procedures could be done by any unlicensed person under the supervision of the physician. Most state medical practice acts give a physician wide latitude in delegating medical acts. The constraints are usually radiation. The limiting factor on this is usually patient satisfaction, liability and the biggest reason - reimbursement.

I'm not sure I understand. In the context of procedures within an out patient setting, what are the procedures an FNP may not perform that a physician may perform?

This is going to depend on your state BON and practice environment. For example in Texas an FNP would probably not be allowed to do colposcopy since this is in the domain of the WHNP or CNM. An FP physician could do this. In the outpatient setting especially any physician, essentially has an unlimited license to practice medicine and surgery. An NP will be limited by their training and certification as defined by the BON.

David Carpenter, PA-C

Dr. Tammy, FNP/GNP-C · Oct 16, 2008

In theory all of these procedures could be done by any unlicensed person under the supervision of the physician. Most state medical practice acts give a physician wide latitude in delegating medical acts.
David Carpenter, PA-C

Perhaps in other states but none of the above may be performed by medical assistants in California. Why? Two main restrictions. First, many of the above require assessments prior to the procedure and assessments in an ongoing manner during and after the procedure. I suppose, though if the physician was in the room, making assessments in real time, this might be OK, but the invasive procedure nature trumps this. Second, in California, medical assistants may not perform any form of invasive procedure.

Here are a few quotes from the California Medical Board regarding MA's

http://www.medbd.ca.gov/allied/medical_assistants_questions.html

Are medical assistants allowed to chart pupillary responses?

No. The charting of pupillary responses is considered an assessment, which is a form of interpretation. Medical assistants are not allowed to read, interpret or diagnose symptoms or test results.

Are medical assistants allowed to insert urine catheters?

No. Insertion of a urine catheter is considered an invasive procedure and therefore, not within the medical assistant's scope of practice.

Are medical assistants allowed to administer chemotherapy and/or monitor patients?

No. Medical assistants are not legally authorized to administer chemotherapy or make an assessment of the patient as the procedure does not fall within the medical assistant's scope of practice.

the medical assistant's scope of practice. Please reference CCR Section 1366(b)(3).

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Are medical assistants allowed to interpret the results of skin tests?

No. Medical assistants may measure and describe the test reaction and make a record in the patient's chart. For every questionable test result, the result should be immediately brought to the physician's attention. In addition, all results need to be reported to the appropriate provider. Please reference 16 CCR 1366(b)(2).

core0 · Oct 16, 2008

Perhaps in other states but none of the above may be performed by medical assistants in California. Why? Two main restrictions. First, many of the above require assessments prior to the procedure and assessments in an ongoing manner during and after the procedure. I suppose, though if the physician was in the room, making assessments in real time, this might be OK, but the invasive procedure nature trumps this. Second, in California, medical assistants may not perform any form of invasive procedure.
Here are a few quotes from the California Medical Board regarding MA's
http://www.medbd.ca.gov/allied/medical_assistants_questions.html
Are medical assistants allowed to chart pupillary responses?
No. The charting of pupillary responses is considered an assessment, which is a form of interpretation. Medical assistants are not allowed to read, interpret or diagnose symptoms or test results.
Are medical assistants allowed to insert urine catheters?
No. Insertion of a urine catheter is considered an invasive procedure and therefore, not within the medical assistant's scope of practice.
Are medical assistants allowed to administer chemotherapy and/or monitor patients?
No. Medical assistants are not legally authorized to administer chemotherapy or make an assessment of the patient as the procedure does not fall within the medical assistant's scope of practice.
the medical assistant's scope of practice. Please reference CCR Section 1366(b)(3).
Back to Top
Are medical assistants allowed to interpret the results of skin tests?
No. Medical assistants may measure and describe the test reaction and make a record in the patient's chart. For every questionable test result, the result should be immediately brought to the physician's attention. In addition, all results need to be reported to the appropriate provider. Please reference 16 CCR 1366(b)(2).

California can probably be considered unique in its regulatory environment that is why I put in most states. I have seen all of the practices above preformed by UAPs at different times in different states. All legally.

For example Colorado states:

(3) Nothing in this section shall be construed to prohibit, or to require a license or a physician training license under this article with respect to, any of the following acts:

(stuff deleted)

(l) The rendering of services, other than the prescribing of drugs, by persons qualified by experience, education, or training, under the personal and responsible direction and supervision of a person licensed under the laws of this state to practice medicine, but nothing in this exemption shall be deemed to extend or limit the scope of any license, and this exemption shall not apply to persons otherwise qualified to practice medicine but not licensed to so practice in this state;

Two things define non-physician providers ability to provide services.

1. Our ability to independently make decisions about medical care

2. Ability to bill under Medicare and other insurers because of number one.

A list of procedures does not make a clinician.

David Carpenter, PA-C

mom and nurse · Oct 19, 2008

My program attracts a lot of people interested in becoming NPs. I'm looking more towards the CNS role, as I'm looking for something more hospital-oriented and specialized. I've never wanted to do the kind of primary care my PCP does (and I'm not looking forward to yet more school).
But I really like and am good at basic physical assessment, which is something more associated with NPs (and is in fact taught by NPs for both the lab and lecture sections). So, I'm starting to wonder if I am right about the NP role.
So what is it that you all do?

I work in a rehabilitation hospital as an Adult NP. I work as a team with a physician. (Though I am licensed in Washington DC which does not require a collaborative agreement with a physician). Our patient population is more stable than what you see in an acute care hospital. I round to see patients sometimes with the physician and sometimes on my own. We work as a team, I check off the orders for the new admissions, do the medication reconciliation, dictate the information for the discharges (which is then signed by the physician), write the prescriptions.

I spend a lot of my time educating the patients and their family members as to disease processes and procedures. I explain their medications, etc. I answer questions for the therapists, and other Registered nurses. (I am very grateful for those who are at the bedside... I always thank the RNs who are doing what I was doing 2 short years ago...as well as the Nursing Assistants). When a call comes in from a family member, usually I am the one who receives the call....

I enjoy my role as a Nurse Practitioner.....