Can NPs work as RN's?

Advanced Practice Columnist / Guide · Dec 18, 2006

You may not have understood from my post that our role involves managing ICU patients who underwent heart and lung surgery. We work under collaboration with the intensivist in the CTSICU (who happens to be a surgeon who underwent further training in trauma and critical care). That's why we are under Trauma and Critical Care Services and not Cardiothoracic Surgery. ICU patients need an ICU admission consult and daily ICU notes - that's a requirement for all ICU patients regardless of what insurance they have. These notes are signed by the intensivist during rounds but if it is an NP that completed the documentation, it is billed under the NP and not the physician, that is what the regulations say.

As far as procedures, I don't undesrtand how you can overcharge when you do procedures individually. The same applies to these procedures as I've said above - if the NP did them, even if the MD signed the procedure note, it is billed under our name.

You're right the CT surgeons do not need to write notes daily although they do round with us every morning with the intensivist. We don't work for the CT surgeons, we just watch their patients - get it?

I am aware of the 85% rule only applying to Medicare patients. What do you think is the biggest bulk of payer source for the CT surgery population? They are mostly over 65 and on Medicare! As for the younger patients, we still win because even if the notes were billed under the physician, they are detailed and are billed at the highest possible code. The intensivist did not spend as much time as we did writing those notes, we did, but in the end the hospital receives revenue for them so we all win.

core0 · Dec 19, 2006

you may not have understood from my post that our role involves managing icu patients who underwent heart and lung surgery. we work under collaboration with the intensivist in the ctsicu (who happens to be a surgeon who underwent further training in trauma and critical care). that's why we are under trauma and critical care services and not cardiothoracic surgery. icu patients need an icu admission consult and daily icu notes - that's a requirement for all icu patients regardless of what insurance they have. these notes are signed by the intensivist during rounds but if it is an np that completed the documentation, it is billed under the np and not the physician, that is what the regulations say.
ok i understand what you are doing. we don't use too many surgical intensivists around here. mostly the ct surgeons handle their own patients and call in medical intensivists for medical issues. there is a method that you can use to increase the billing if you want. this is called co-billing. the only thing that you need to do differently is to have the physician participate in any part of the care plan. for example they can do their own physical exam or they can discuss the care plan with the patient - just need to document it. then you can bill under the physician id at 100%. for example the physician can write, "i discussed the plan of care with the patient and answered questions about x". just need to do more than signed and reviewed.
as far as procedures, i don't undesrtand how you can overcharge when you do procedures individually. the same applies to these procedures as i've said above - if the np did them, even if the md signed the procedure note, it is billed under our name.
you can't i was referring to the rounding. i don't have much experience in this, but my understanding is that you bill under your provider number.
you're right the ct surgeons do not need to write notes daily although they do round with us every morning with the intensivist. we don't work for the ct surgeons, we just watch their patients - get it?
that would be hospital policy on writing notes. medicare still expects them to provide follow up care. who follows these patients on the floor?
i am aware of the 85% rule only applying to medicare patients. what do you think is the biggest bulk of payer source for the ct surgery population? they are mostly over 65 and on medicare! as for the younger patients, we still win because even if the notes were billed under the physician, they are detailed and are billed at the highest possible code. the intensivist did not spend as much time as we did writing those notes, we did, but in the end the hospital receives revenue for them so we all win.

good notes are helpful for documentation for charges, but they are just to support the level of care. the level of care is really determined by the medical decision making, level of complexity and coordination needed. also if you spend a lot of time educating/counselling the patient you can code by time if counseling >50% of the time. i find thats one part that many providers forget.

david carpenter, pa-c

Advanced Practice Columnist / Guide · Dec 19, 2006

You're not telling me anything I don't already know so let's just stick to the topic of the thread. So can NP's work as RN's?

Who's following the patients on the floor? the CTS PA's, they work under the CT surgeons.

core0 · Dec 19, 2006

You're not telling me anything I don't already know so let's just stick to the topic of the thread. So can NP's work as RN's?
Who's following the patients on the floor? the CTS PA's, they work under the CT surgeons.

Since you asked for it, this is the best explanation that I have seen:

"I am a family NP (FNP) and am wondering if I can work as a non-advanced practice RN at a local nursing home? I plan to function as any other RN. Would I be held to higher liability standards?

From a regulatory standpoint, you are always legally entitled to work under your RN license, as long as it is current and you meet all RN requirements. However, insurers agree that someone with advanced practice training and certification needs to be insured at the higher level, regardless of position. See the NSO newsletter answering this topic at: Nursing medical malpractice / professional Liability Insurance, newsletter, articles, continuing education, and legal case study for RN, LPN, nurse practitioner, clinical nurse specialist.

Role validation is a large component of scope. If you take such a job, you will need to ensure that the role validation of the RN, rather than that of the NP, is the face you hold out to the public. The setting where you are employed can also help match your role validation, by keeping your job title, job description, duties, and activities crystal clear. The most conservative advice would be to avoid working in areas that share the specialty of your advanced practice focus (such as a nurse midwife working as a labor and delivery nurse). Taking such a position is asking for role confusion, and that, in turn, affects your ability to practice appropriately with your patients."

David Carpenter, PA-C

mingus_lost · Dec 19, 2006

The most conservative advice would be to avoid working in areas that share the specialty of your advanced practice focus (such as a nurse midwife working as a labor and delivery nurse). Taking such a position is asking for role confusion, and that, in turn, affects your ability to practice appropriately with your patients."

Wow. This adds a whole extra layer of complication for those of us considering masters entry APRN programs. I've seen it advised on this board that MEPN students plan to work as RNs for a few years in their specialty area before seeking, or at least expecting, their first APRN job. However, if my employer and I would have to assume additional liability due to my advanced training and/or there is likely to be a reluctance or ethical dilemma with hiring me as an RN in my specialty area, the MEPN route begins to look like it will create a catch-22 for me.

I really think universities would be wise to open more accelerated BSN programs instead of so many MEPNs. At least in my case, the MEPN is on the table because it is the only logical way into nursing around here, but I think an accelerated BSN would be a better choice for me if it were available. Then I could get some experience and take it from there.

mvanz9999, RN · Dec 19, 2006

While what you say is true, I simply do not see any other way in for me. I mean, I'm not 20 any longer, and I simply do not have the time or desire to get a second bachelors, while planning on getting a masters eventually, anyway. Why not just get it now. We all gone through school already.

surgpa · Dec 19, 2006

There's some truth to your remark for hospitalist NP's who only do H&P's and progress notes. But even those NP's can bring revenue to a hospital. I belong to a group of critical care NP's hired under our Department of Surgery's Trauma and Critical Care Services. We manage patients in the cardiothoracic surgery ICU and perform invasive procedures in addition to H&P's, consults, and daily ICU notes. We charge for each A-line, central line, chest tube, Swan-Ganz we put in. Our H&P's and progress notes are way more detailed than senior ICU staff. We have gotten kudos from our coders because they can get the highest revenue codes for our documentation and this translates to higher profits despite the fact that we can only claim 85% of the fee. I think it's all a matter of spreading the word to physicians about what we can do. Our collaborating physician has been such a great advocate for NP's. She even helped us with strengthening our case for a raise and yes, she is a female surgeon and the most awesome one I've met!

My question is this. Does the hospital factor your salaries into the general overhead, or do they bill for your services individually? There is a danger to all of you if you are being paid under a global charge for the general overhead billed to Medicare and then billing out individual procedures as you describe. I have seen this before because few administrators realize they are double-billing Medicare or another insurance, when the audits come, who do you think pays for it?

Trube · Dec 19, 2006

I agree totally. I enjoyed working as a RN, but chose to go back to school because I wanted more.

I know of one NP whose specialty Spine practice closed when the surgeon he was working with retired. Desirous of a new position close to home, with benefits, he tried working as a RN on the spine floor of the local hospital.

He found it difficult stepping back and trying to work as an RN rather than an NP.

Speaking for myself, the autonomy, respect from many (not all) and financial rewards make being an NP very rewarding for me. At the end of my NP program, I was burned out and was dreading a career I just spend another huge chunk of $$$ on. Once I graduated and started working, I found much enjoyment, and am constantly amazed at the opportunities presented to me any my fellow NP / PA counterparts.

Advanced Practice Columnist / Guide · Dec 19, 2006

My question is this. Does the hospital factor your salaries into the general overhead, or do they bill for your services individually? There is a danger to all of you if you are being paid under a global charge for the general overhead billed to Medicare and then billing out individual procedures as you describe. I have seen this before because few administrators realize they are double-billing Medicare or another insurance, when the audits come, who do you think pays for it?

We're all employees of the hospital. Even the docs are part of the hospital medical group exclusively, most docs in our hospital do not even have priviledges somewhere else. It's a closed medical practice that involves the whole health system - the main hospital, a few satellite hospitals and clinics, and a network of primary care clinics around Metro Detroit. The sytem also owns an HMO that is one of the largest in the state. This is not some rinky-dinky health system. It is one of the largest and most respected in Metro Detroit. The main hospital is a quaternary referral center. Billing is done by the hospital, not by individual providers. However, we have to indicate the cost center when we document so it can be determined which department generated the revenue. Trust me, we know what we are doing. We receive a salary from the hospital regardless of whether you're a physician or a midlevel - docs are salaried, midlevels are also salaried but can get overtime pay.

mvanz9999, RN · Dec 19, 2006

I agree totally. I enjoyed working as a RN, but chose to go back to school because I wanted more.
I know of one NP whose specialty Spine practice closed when the surgeon he was working with retired. Desirous of a new position close to home, with benefits, he tried working as a RN on the spine floor of the local hospital.
He found it difficult stepping back and trying to work as an RN rather than an NP.
Speaking for myself, the autonomy, respect from many (not all) and financial rewards make being an NP very rewarding for me. At the end of my NP program, I was burned out and was dreading a career I just spend another huge chunk of $$$ on. Once I graduated and started working, I found much enjoyment, and am constantly amazed at the opportunities presented to me any my fellow NP / PA counterparts.

I'm not really sure what you're agreeing to, but this is a very nice and refreshing post.

BrandyNP · Jan 2, 2007

The reason that you don't see many hospitals employing NP's is economics. The RN salary is simply supply/demand. Not many nurses/lots of demand = high salaries. This is compounded when there are laws (California) or regulation (hospital rankings) that demand certain nurse staffing ratios.
The NP situation is somewhat different. It is very difficult for a hospital to charge for NP services. There are rare cases where it may make financial sense to hire an NP for certain services. Also it may be helpful for a hospital to hire an NP to retain certain physician services. Here though there is not as much competition and there is no income to offset the salary. Also remember that many NP's are salaried as opposed to staff nurse which are hourly (a source of additional income). I have actually seen cases where if you took an hourly rate for the NP they are below the pay for a staff nurse.
David Carpenter, PA-C

NP's in South Texas are earning more than R.N.'s. Neonatal NP's are making over 100K with full benefits and they are working three 12 hour shifts per week. The ER NP's are pulling in about $45 per hour with full benefits. The RN's average about $30/hr (more in ICU) with full benefits in this area. I work as an independent contractor, so I average more (but no benefits or job security).

BrandyNP · Jan 11, 2007

We have a big debate going on right now, once I get my NP can I still work as a "regular" RN? or am I always going to have to take a job as an NP?

Of COURSE you can work as a RN! I kept working as an RN (weekends) for over 8 months after becoming a NP. I was an NP during the week and a RN on weekends. You will have your pick of RN jobs if you're an NP.