Should nursing charges be separate from the room charges?

Gardengal · Mar 6, 2003

I think that one of the reasons charges are higher for some of the items we use when we do bill for them is because it costs to use them-ie foley charges, ng, etc. -cost to hospital is way different than to the patient.

I can't think how we could bill for the critical thinking which is what differentiates nurses from techs. One of our biggest frustrations is that we spin our wheels coordinating all sorts of activities all at the same time. Kind of tough to bill that to one individual. Easier to group it as a charge in toto.

Perhaps we could differentiate nursing charges based on where a patient fits into an acuity scale, but I still see a data entry work increase...is it worth it?

a couple of other points-I don't think it's a male female thing. Our pharmacy, pt and xray departments are led by women.

Also, I recall reading a book years ago about paternalism with hospitals and vaguely recall this topic (probably the same book referred to by Edward)-I believe our health care environment has changed quite a bit since the publishing date of 1975. Afterall DRGs came out in the mid 80s-and finances have gone down since then.

ryaninmtv, ADN, ASN, BSN, MSN, LPN, RN · Mar 6, 2003

Nursing charges can be billed in excess of the room rate. On the standardized hospital bill (UB-92), these would normally fall under the 230 and 240 revenue codes. The description is for "comprehensive nursing services". This is most often seen in burn units where they are billing for debridement treatments, whirlpool baths, and the like. I have also seen this code used in combination with ICU charges for very involved patients. It's not that the codes don't exist, it's that hospitals don't bill for it. Medicare and Medicaid both reimburse for nursing charges (albeit not that much) but there is some payment.

It's not that it can't be billed for, it's that your hospital isn't billing it. See, you are important. :)

SmilingBluEyes · Mar 6, 2003

A succinct "yes" is my answer. The above posts clearly give reasons why; I have no original thoughts to add. Just that I agree with those that believe we should charge for nursing services....

llg, PhD, RN · Mar 6, 2003

Great thread.

I remember this was one of the hot topics back in the late 1970's when I was in my Master's program. It's interesting to see it still being discussed today -- and remaining unsolved.

I think (but am not 100% sure) that a lot of that talk 20-30 years ago led to the development of acuity systems and accommodation codes. By charging different "room rates" for patients with different acuity levels, hospitals tried to charge more for those patients who required more nursing care -- while not bogging down the system trying to capture individual charges for each specific task the nurse did. (e.g. fluff pillows = $1.00, start IV = $30.00, be supportive to family = $50.00, etc.)

Over the course of my career, I have worked with a few different acuity systems that tried to document how much nursing time was spent on each patient per day. The patient was then charged a "room rate" that was based on the acuity score. Also, the amount and type of nursing staff assigned to that unit was then based on the acuity numbers.

3rd party payors and JCAHO used to require that acuity systems be in place and that they be routinely monitored for validity and reliability. The fear was that without that constant monitoring, staff might be inflating the acuity numbers in an attempt to get more staffing on their unit than "really needed" and that hospitals would then be over-charging the patients. (That's a whole other story that would make this post waaaaaaay tooooo loooonnnngggg.

Anyway, with changes in funding and experience with acuity systems, they have become less the rage than they used to be. JCAHO stopped requiring big fancy systems a few years ago.

Interestingly, computer companies jumped on the bandwagon a few years ago and started developing complex systems that record acuity as part of staffing and scheduling programs. These programs cost hundreds of thousands to purchase and install and almost as much to maintain. However, now that the products are starting to come to market, the market for them is no longer as great as it once was.

llg

dingofred · Mar 6, 2003

This is a facinating thread and a topic I've not

given much thought to. I agree that it would be cumbersome trying to track all that a nurse does during a shift, or heck, even an hour sometimes.

I also believe that this type of billing will never come into existence because as one poster pointed out, it would put value on the service.The topic certainly gives me something to mull over!! :rolleyes:

deespoohbear · Mar 7, 2003

I tried to keep track in my head today everything I did that only a nurse could do and this is the list I came up with:

2 IV starts

1 d/c IV

1 IV to SL

1 foley cath d/c

2 admissions

3 prn's given

1 tele unit applied

1 PCA d/c

countless routine meds administered

I am sure there are other things I did today that could be classified as nursing procedures, but after a 12 hour shift I am brain dead....

These are all procedures that have to be done by an RN or a LPN (depending on your state practice act). Have a couple patients that required very little nursing time and others who required a lot of my time. But they will be charged the same rate for the rooms.....doesn't seem right for the patient who required less care. :confused:

Gardengal · Mar 7, 2003

Deespoohbear- I see you did what I did today, assessed what you did and thought about what could be billed. Ifind myself thinking that I belittle the nursing profession though by trying to state the tasks.

For example, taken from your list:

Started 2 IVs and discontinued an IV. I believe that your task was more than a task. You probably either had bad IVs or needed additional lines based on your knowledge of incompatability of meds and need for further. You started a new IV-I bet you probably taught the patient about what you were doing, allayed anxiety, gathered supplies, performed the procedure, assessed tolerance of the procedure and then used the new line for whatever reason you started it for - and then assessed tolerance for that. You then had to document this.

The 3 prns you gave-You assessed your patients, decided they needed the meds, administered the meds, documented them, assessed efficacy and then documented more.

For each of your interventions I see that we would underestimate our worth, if we can't spell it all out. I agree that it doesn't seem right to bill to the lower acuity patient the same as another which requires more care.

Should we try to bill based on tasks though? Or more for the level of care which most hospitals seem to average out by billing for a type of bed and assigning a cost. ie regular nursing floor, telemetry, step down or ICU.

I see why you would have been tired after your 12 hour shift, but I see it because I am attributing each task with an assumption about your patients needs.......it sounds like telemetry since you put a telemetry pack on one.......

I don't know. I agree that we should be able to bill for nursing, but until we as a profession in general can assign an average cost to a standardized acuity level it sounds like just more work added to our plates.

.......too many questions for my tired old mind today....

altomga, ADN, BSN, MSN, DNP, RN, APRN · Mar 7, 2003

I have been reading the new posts as they come and see that many people have mentioned the acuity scale to base a room charge on.......

At my hospital we use a medicus system to classify pt's acuity with, but it is only to "prove" we need the staff that is scheduled!!!!!!!

Okay we have 6 "pods" 1-4 rn/pt ratio and only 2 aides at night, one secretary....

Lets count total rn's 7 (with a float charge rn)

10 staff on nights for 24 critically ill patients all on telemetry that is monitored by the nurse taking care of the pt's only, 2 aides for 24 total care pts, and one secretary.

Does it take a rocket scientist to figure we need the staff....

They would never dream of increasing the room charge due to increased pt workload.....

Oh but if dreams came true!!!!!!!!!!:chuckle

Edward,IL · Mar 7, 2003

This certainly is an interesting thread.

a few more thoughts:

1) We have often times said "Nurses handle too much information in too short a time to be able to keep track of it". We do process ALOT of information during an 8-hour shift providing care to as many as 10 patient's. Computers won't ever capture it all, but can perhaps help us record at least 75-90% of what we do.

Many of the computer/acuity systems out there were developed by non-nurses and are not a good fit. People outside of nursing often times see nursing as just task-oientd rather than the complex set of clinical judgements being made within the context of the nursing process.

The best classification system I've seen to date (and use every day in practice)

is the Nursing Intervention Classification(NIC) developed at the University of Iowa, McCloskey Joanne C., and Bulecheck, Gloria M. This is research based and gives labels for nursing and corresponding (mutually exclusive) numeric codes that can be used to track patient consumption of nursing resources. This is a universal system that can be used by all nurses in all settings. Take a look at this and select the nursing interventions that you use with your specific patient populations.

You may find that there are perhaps 20-30 most common to your unit. This becomes your focus for beginning to keep data on nursing resource utlization. After tracking patients in this way for say 6-12 mos, you have some fairly meaningful data that gives a less fuzzy picture of what you are doing ith your nursing resources. The minute details such as I.V. starts, dressing changes, feeding a patient, safety surveillance, etc fit nicely as activities under the label headings. This allows for the individualization of the patient's careplan and continuity of care.

Take the information gleaned from say 50-100 patient care plans and throw it into the hopper and see what aggregate data you have. This gives an answer to those pesky administrators when they walk on the unit asking "What have you girls been doing all day?"

2) An accompanying volume (when you are ready to take the next step) is the NursingOutcomesClassification(NOC),,Johnson, Marion, and Maas, Meridean. This is a separate but well-fitting system to measure those outcomes and be able to really evaluate how well you are doing (or perhaps provide the information you need to support your claim that you need more staff on the night shift!)

We all have to begin somewhere, each nurse and each unit is unique. This gives us a common language across settings that makes conversation much more sensible.

I suggest everyone get thee volumes and begin using them immediatey in all nursing settings. If you haven't yet had coffee and are a little slow to start, at least visit their web-sites. Start at NANDA and follow their links to NIC and NOC This is some really exciting stuff going on in nursing these days and can improve your mood.

Let me know what do you think.

Edward.

jemb · Mar 8, 2003

I've thought about this before, too. Don't know how you would bill by tasks -- too many of them -- not to mention the critical thinking aspects of nursing. It would have to be some sort of insurance type codes -- probably based on nursing diagnoses or such.

Then there should always be the extra charge/ special code for PIA patients and the patients of the PIA docs!

OC_An Khe · Mar 8, 2003

The answer is YES. Maybe then the suits would realize that Nursing is a source of revenue and needs to be grown as opposed to a cost center that nedds to be limited.

Gardengal · Mar 8, 2003

I look forward to learning from the publications cited by Edward, IL. It's a topic of great interest to me, but it looks like it will be a while until I can get it all read and digested.