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PA's rounding on patients

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At the hospital I'm currently working at one of the PA's that I work close with told me that as of January 2011 they are no longer allowed to round on patients in the hospital. I was unable to ask him at the time "why", but someone else told me it's an insurance reimbursement thing???? I'm confused, I'm thinking it's the hospital I'm working at is making up this new policy. By the way we are a teaching hospital. Has anyone else heard of this??? They are saying this doesn't apply to NP's.

At the hospital I'm currently working at one of the PA's that I work close with told me that as of January 2011 they are no longer allowed to round on patients in the hospital. I was unable to ask him at the time "why", but someone else told me it's an insurance reimbursement thing???? I'm confused, I'm thinking it's the hospital I'm working at is making up this new policy. By the way we are a teaching hospital. Has anyone else heard of this??? They are saying this doesn't apply to NP's.

Call the CEO and ask him.

I noted one time that my daughter was seen by someone who had "PA" on their name tag, but when the bill for services came it listed the name of an MD. I always thought that there was a misrepresentation for insurance purposes. If you are seen by a PA, then the reimbursement should be for the "PA" rate and not the "MD" rate. Let us be honest.

traumaRUs, MSN, APRN, CNS

Specializes in Nephrology, Cardiology, ER, ICU. Has 27 years experience.

The problem is that if you are seen by a mid-level and the MD in the same day,, you obviously can't bill for both services. So, its not that the PA isn't allowed to round on the pts, the MDs may just figure why pay for a mid-level when they can't bill for their services?

at the hospital i'm currently working at one of the pa's that i work close with told me that as of january 2011 they are no longer allowed to round on patients in the hospital. i was unable to ask him at the time "why", but someone else told me it's an insurance reimbursement thing???? i'm confused, i'm thinking it's the hospital i'm working at is making up this new policy. by the way we are a teaching hospital. has anyone else heard of this??? they are saying this doesn't apply to np's.

there are no new regulations. either they were doing something incorrectly and got caught or they want to increase reimbursement as below. the rules for nps and pas for inpatient work are essentially identical under medicare and most insurance companies.

check out:

are you collecting illegal dollars for "incident to" services ...

higher reimbursement when physicians providing care....

good article but incident to does not apply to inpatient work. there is a similar concept called shared billing where the physician and the pa (or np) can see the patient with the physician duplicating one part of the e/m encounter and bill 100% under the physicians npi number.

in reality the extra cost of the physician rarely makes up for the extra 15% reimbursement. essentially there are three reasons that physicians employ nps and pas

1. there are not enough people to do the work.

2. there are enough people to do the work but there is a lifestyle penalty (ie getting home every day at 9pm).

3. there are enough people but the work being done is done at the expense of more lucrative work (ie cardiology is seeing patients for lipid adjustment when they could be cathing people).

in the first case bringing in a pa or np is just like bringing in a physician with the exception of the lower reimbursement (and lower salary). in the second what the physician is doing is essentially paying someone else so that they can have a life. they should understand that their income will go down but life satisfaction should go up. in the third case the income for the physician will go up. the np or pa may not bill enough to cover their cost but the added billing for procedures more than makes up for it.

you also have to look at incremental costs. if you have a hospitalist service with a physician and pa (or np) and they are exactly getting things done without shared billing. if you hire another physician is the extra billing for shared billing going to be enough to justify a physicians salary (answer probably not). we use this system for our icu. the pas and nps have their own patients and manage them autonomously. the attending rounds with the residents and bills for that time. he then rounds with the pas and nps and provides any input necessary but does not bill for our work. all the billing is done under our names. if they did shared billing on the e/m patients (as opposed to critical care time) they would make more money. given that they are already among the top billers in the hospital they don't think thats a productive use of their time. in another icu with more e/m all of the e/m patients are billed under shared billing. it just depends on whether the extra 15% is worth their time.

i noted one time that my daughter was seen by someone who had "pa" on their name tag, but when the bill for services came it listed the name of an md. i always thought that there was a misrepresentation for insurance purposes. if you are seen by a pa, then the reimbursement should be for the "pa" rate and not the "md" rate. let us be honest.

if the patient is a medicare/caid patient then the billing will be under the pa unless it is shared billing (see above). for most private insurance their is no "pa rate". instead the insurance companies instruct the providers to bill under the physicians npi as they are credentialed with the insurance company. no misrepresentation just what the insurance companies want to do. works exactly the same for nps.

the problem is that if you are seen by a mid-level and the md in the same day,, you obviously can't bill for both services. so, its not that the pa isn't allowed to round on the pts, the mds may just figure why pay for a mid-level when they can't bill for their services?

see above for shared billing. since this is being applied to pas and supposedly not to nps i am guessing that this relates to surgery (where pas have a heavier representation). in surgery the care is paid as part of a 0, 30 or 90 day global bundle. what this means is that the surgeon gets one fee for the surgery which includes follow up care for the next 0, 30 or 90 days. this includes hospital care. in the past many surgeons used pas to manage the inpatients which allowed them to spend more time in surgery. this was essentially unreimbursed time but ideally the physician income was increased by the increased surgery (see #3 above). if the practice has decided to increase income by moving the pas back to the clinic where they are reimbursed for services and have the physicians do the inpatient work (which they have already been paid for) then that is one possible interpretation. note this is in no way a new "policy". it also is possible there is something else up and the op misunderstood the context.

david carpenter, pa-c

Edited by NRSKarenRN

ghillbert, MSN, NP

Specializes in CTICU. Has 20 years experience.

David, thanks for the excellent info - really helpful. I am an NP student with little US hospital experience and am rather thick with billing stuff. Can you explain further what you mean by the following:

If they did shared billing on the E/M patients (as opposed to Critical care time) they would make more money. Given that they are already among the top billers in the hospital they don't think thats a productive use of their time. In another ICU with more E/M all of the E/M patients are billed under shared billing

What's an E/M patient? What's the difference btw E/M time and critical care time?

Thanks for any info!

David, thanks for the excellent info - really helpful. I am an NP student with little US hospital experience and am rather thick with billing stuff. Can you explain further what you mean by the following:

What's an E/M patient? What's the difference btw E/M time and critical care time?

Thanks for any info!

Its a little more complicated than this but there are two ways to bill for inpatients with medicare. One is called evaluation and management (E/M) and the other is critical care time.

E/M is what you use in everyday encounters on the floor. Basically every encounter has three elements that you must do.

History of the present illness (or interval history)

Physical Exam

Assessment and plan.

The documentation is key here. For example if I see a patient in follow up and I want to bill for a high level I know that I have to document the following:

Detailed Interval history

A physical exam with 5-7 systems covered

A/P that shows high level of medical decision making, a significant complication or significant new problem

Looking at my handy matrix like the one here:

http://www.algosresearch.org/Education/StartingPractice/EMmatrix.htm

I would code this a 99233 which is an inpatient follow up high level.

Basically the CPT code that you submit has an assigned value from Medicare based on how much work you do and reimburses a certain amount. All of the other insurance carriers use these codes to decide how much to pay you. No matter how much time you take you get paid the same amount if you bill for a particular code (again a little more complicated than this but thats the basics).

Critical care billing is different. Its purely based on the time that you spend with the patient or on the unit working on the patient (looking up labs, writing the note, conferring with specialists etc). The key is the patient has to be critically ill. This is defined as:A critical illness acutely impairs one or more vital organ systems, which means that a patient's condition has a high probability of imminent or life-threatening deterioration.

So for example tonight I accepted a patient from the OR after a 12 hour surgery. The patient was intubated, on pressors, hypotensive and oliguric. So from a critical illness standpoint they have critical illness that impairs their lungs, heart/brain and kidneys. Pretty easy to justify critical care time. I stabilize the patient, read through the chart and document their past medical history and do a physical exam. I spend the next 3 hours stabilizing them, volume resuscitating them, titrating pressors and manipulating the vent. Of that time I spend thirty minutes putting in a central line under ultrasound and putting in an art line under ultrasound (I would like to thank anesthesia for deciding to do this case with peripheral IVs and transport for pulling out the Art line putting the patient in the bed). At the end of the night I would code this as follows:

99291 critical care time first 30-74 minutes.

99292 critical care time next 30 minutes x 3

This equals 2 1/2 hours or 150 minutes broken down into 75 + 30 + 30 + 15 (the last 15 is half of a 99292 so you can bill the whole code).

Since certain procedures are billed separately and not included in the CCM time, I also billed for

36556 central line

76937 with U/S

36620 Arterial Line

76937 with U/S

Each CPT code has a revenue value unit (RVU) assigned to it. Medicare in these neck of the woods pays around $33 per RVU. A 99291 pays 4.5 RVU and a 99292 2.25 RVU. So excluding the procedures the hospital would receive around 11.25 RVUs or around $350 for my three hours work plus the lines which pay around $400 x .85 for being a PA or NP or around $650 for three hours work. Not too shabby.

Now lets say that I spent the same three hours doing follow up visits on three complex patients who were not critically ill. I would bill 99233 for a high level visit x 3. A 99233 pays 2.0 RVU so the hospital would get 6.0 RVUs or around $200 x .85 or $170 for the same three hours work. If you could see six patients in that same time you would make almost as much as the critical care time (without the procedures). Of course medicare expects you to spend at least 35 minutes on each 99233 so even if you did the minimum time with all of them you still make less than doing critical care time

The final piece is whats called shared billing. In this case the NPP must do all three of the elements of the E/M code. Then the physician separately sees the patient and documents participation in one element of the E/M code. This can then be billed under the physician at the physician fee at 100%. So if I saw 5 patients in three hours and then the physician came and discussed the plan with them (for example) and documented it, you would make 15% more (or $330 vs $280) with the mythical five high level follow ups.

For some groups its better having physicians see their own patients and generate more RVUs. With others the extra money is worth the extra effort. In our case since the physicians can make more money doing CCM time on other patients (are are the top billers in their group) its not worth the time to do shared billing on E/M patients in the ICU.

This just touches the tip of billing which is all and all very complicated.

David Carpenter, PA-C

juan de la cruz, MSN, RN, NP

Specializes in APRN, Adult Critical Care. Has 27 years experience.

David,

I know you guys do not do shared billing but on the issue of shared billing, how does your practice interpret the CMS guideline that states: "The shared/split billing option only applies to evaluation and management services provided in an emergency department, outpatient or inpatient hospital. It excludes consultations and critical care services"? It seems to me that shared billing can not be used in critical care at all or am I misinterpreting the guideline.

Source: http://www.the-hospitalist.org/details/article/186112/Reimbursement_Rights_.html

ghillbert, MSN, NP

Specializes in CTICU. Has 20 years experience.

David, you rock! Thank you so much for taking so much time to explain simply what I am sure is even more complex than you make it :)

David,

I know you guys do not do shared billing but on the issue of shared billing, how does your practice interpret the CMS guideline that states: "The shared/split billing option only applies to evaluation and management services provided in an emergency department, outpatient or inpatient hospital. It excludes consultations and critical care services"? It seems to me that shared billing can not be used in critical care at all or am I misinterpreting the guideline.

Source: http://www.the-hospitalist.org/details/article/186112/Reimbursement_Rights_.html

Critical care services refers to the activity not the place. You can bill critical care on the floor and bill E/M in the ICU. One of the cardinal points of critical care billing is that you rarely (almost never) bill critical care time on the day of discharge from the ICU. The point is that if they are stable enough to go to the floor then they are stable and don't qualify for critical care time. Essentially you only bill shared billing for the stable patients where you are billing E/M.

For example if I go to a code met and stabilize a patient then I can bill for my critical care time on the floor. Similarly if I have written transfer orders for a patient and they are waiting around for a floor bed they are obviously not critical and I would bill E/M for them. In reality probably 40-50% of our ICU players do not meet critical care guidelines. We have a lot of patients that come out late from the OR after big surgeries. They are watched overnight in the ICU and then transferred to the floor the next day. Endovascular aneurysm repairs (EVAR) are one item. We have an agreement with vascular surgery that all EVARS will come from the OR to the ICU. Most of them arrive with no issues and spend the night watching TV. Occasionally they act like the vasculopaths they are and do all of the things you would expect (NSTEMI, STEMI, Bleeding aortic aneurysm, renal failure, sepsis etc.). In the first case you do a hospital consult (really a hospital initial patient E/M since there are no more consults). Then E/M the next day. On the other hand if they come up in shock and you are resuscitating them for the next few hours you bill critical care time.

The other thing that you have to remember is that more than one person can bill critical care time, just not at the same time. For example if I am resuscitating a patient and I move to put in a central line (paid for outside of critical care time), then the attending can take over the resuscitation and bill for that time. When I'm done they can either continue to direct the resuscitation or let me take it back. In that case I would bill for my time and the procedure and they would bill for theirs.

Consider the trajectory of a mostly normal patient:

POD 0: Arrives status post ex lap for bladder perf with abcess S/P debridement. Resucitate treat the shock place the patient on the vent start pressors. CCM time 140 minutes.

POD1: Wean the vent, wean down the pressors, narrow the antibiotics as the cultures come back. CCM time 90 minutes

POD2: Continue vent weaning and off pressors. CCM time 70 minutes:

POD3: Off pressors SBT and extubate - depends on how much weaning you have to do. They no longer have life threatening condition but did at the beginning of the day. You can bill either way. Say a couple tries at SBT and long to wake up. CCM time 80 minutes.

POD4: PT stable. No pressors, extubated. Could D/C to floor but going to OR in AM for hip debridement and further washout. HV3 50 minutes.

POD5: PT back from OR extubated not on pressors. No volume issues. Observe overnight (not critical). HV3 60 minutes

POD6: Tx patient to floor HV3 55 minutes.

Over the course of 7 days I billed CCM for four days and Hospital follow up visit level 3 for three days. We have a program we use to bill and put in minutes for hospital days also so they can measure productivity.

Hope this helps.

David Carpenter, PA-C

juan de la cruz, MSN, RN, NP

Specializes in APRN, Adult Critical Care. Has 27 years experience.

Critical care services refers to the activity not the place. You can bill critical care on the floor and bill E/M in the ICU. One of the cardinal points of critical care billing is that you rarely (almost never) bill critical care time on the day of discharge from the ICU. The point is that if they are stable enough to go to the floor then they are stable and don't qualify for critical care time. Essentially you only bill shared billing for the stable patients where you are billing E/M.

For example if I go to a code met and stabilize a patient then I can bill for my critical care time on the floor. Similarly if I have written transfer orders for a patient and they are waiting around for a floor bed they are obviously not critical and I would bill E/M for them. In reality probably 40-50% of our ICU players do not meet critical care guidelines. We have a lot of patients that come out late from the OR after big surgeries. They are watched overnight in the ICU and then transferred to the floor the next day. Endovascular aneurysm repairs (EVAR) are one item. We have an agreement with vascular surgery that all EVARS will come from the OR to the ICU. Most of them arrive with no issues and spend the night watching TV. Occasionally they act like the vasculopaths they are and do all of the things you would expect (NSTEMI, STEMI, Bleeding aortic aneurysm, renal failure, sepsis etc.). In the first case you do a hospital consult (really a hospital initial patient E/M since there are no more consults). Then E/M the next day. On the other hand if they come up in shock and you are resuscitating them for the next few hours you bill critical care time.

The other thing that you have to remember is that more than one person can bill critical care time, just not at the same time. For example if I am resuscitating a patient and I move to put in a central line (paid for outside of critical care time), then the attending can take over the resuscitation and bill for that time. When I'm done they can either continue to direct the resuscitation or let me take it back. In that case I would bill for my time and the procedure and they would bill for theirs.

Consider the trajectory of a mostly normal patient:

POD 0: Arrives status post ex lap for bladder perf with abcess S/P debridement. Resucitate treat the shock place the patient on the vent start pressors. CCM time 140 minutes.

POD1: Wean the vent, wean down the pressors, narrow the antibiotics as the cultures come back. CCM time 90 minutes

POD2: Continue vent weaning and off pressors. CCM time 70 minutes:

POD3: Off pressors SBT and extubate - depends on how much weaning you have to do. They no longer have life threatening condition but did at the beginning of the day. You can bill either way. Say a couple tries at SBT and long to wake up. CCM time 80 minutes.

POD4: PT stable. No pressors, extubated. Could D/C to floor but going to OR in AM for hip debridement and further washout. HV3 50 minutes.

POD5: PT back from OR extubated not on pressors. No volume issues. Observe overnight (not critical). HV3 60 minutes

POD6: Tx patient to floor HV3 55 minutes.

Over the course of 7 days I billed CCM for four days and Hospital follow up visit level 3 for three days. We have a program we use to bill and put in minutes for hospital days also so they can measure productivity.

Hope this helps.

David Carpenter, PA-C

Oh, I understand situations that call for a Critical Care Note and the requirement to indicate critical care time in the note itself. I also understand E/M codes in particular. I used to work in a facility where we (NP's) billed as part of the critical care service for all our procedures and notes. I am in a place now where we currently do not bill (university-affiliated major academic medical center with large training programs in the form or residencies and fellowships). The argument here is that shared billing for all E/M activities can not be used in critical care per CMS guidelines and that there isn't much of a difference in revenue among ICU's that have NP's bill and those who don't. It seems like the guidelines are clear that shared billing is not to be used in critical care. I used the article from "The Hospitalist" only as a point of reference to the guideline.

Oh, I understand situations that call for a Critical Care Note and the requirement to indicate critical care time in the note itself. I also understand E/M codes in particular. I used to work in a facility where we (NP's) billed as part of the critical care service for all our procedures and notes. I am in a place now where we currently do not bill (university-affiliated major academic medical center with large training programs in the form or residencies and fellowships). The argument here is that shared billing for all E/M activities can not be used in critical care per CMS guidelines and that there isn't much of a difference in revenue among ICU's that have NP's bill and those who don't. It seems like the guidelines are clear that shared billing is not to be used in critical care. I used the article from "The Hospitalist" only as a point of reference to the guideline.

I would label the argument that you can't bill E/M in critical care wrong. The problem is that people mistake what CMS means by service when they say critical care service. We use critical care service to mean the people that provide critical care. CMS uses it in a totally different way. When they say service they mean four very specific methods of billing. They are E/M, critical care, procedures, and (in 2005) consultation (which was a separate form of E/M). CMS very deliberately took consults out of shared billing in 2008. They left shared billing intact for E/M. The statement is that the service can be provided in any setting just like critical care. Here is the CMS guidelines for shared billing:

"Hospital Inpatient/Outpatient/Emergency Department Setting.--When a hospital inpatient/hospital

outpatient or emergency department E/M is shared between a physician and an NPP from the same

group practice and the physician provides any face-to-face portion of the E/M encounter with the

patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number.

However, if there was no face-to-face encounter between the patient and the physician (e.g., even if

the physician participated in the service by only reviewing the patient's medical record) then the

service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate

physician fee schedule rate based on the UPIN/PIN entered on the claim."

Here is the AAPA brief on this:

Shared Visit Billing in a Hospital Setting - American Academy of Physician Assistants (AAPA)

Whether shared billing is worth the effort is going to depend on the payor mix and the staffing mix. I also work for a big university hospital with fellows etc. We have five ICUs with around 100 or so beds. One is staffed solely by NPPs and intensivists, three by residents and NPPs and intensivists, and one by residents and specialists. The unit that is staffed solely by NPPs has a lot of observation patients (ie not critically ill but have to be watched closely). They generate a lot of E/M time. They also have more (relatively speaking) NPPs and intensivists. In their model the intensivist goes around and sees all the patients in the AM and discusses their plan. In our model we are expected to move any patients we can out before the intensivist rounds in the afternoon so they don't have to see them. In the first model the 15% probably adds $15k a month or so. In our model we could add another $2-3k per month but that would mean the physician would have to stay another 2 hours later per day. Since they are already there pretty late most days and up most of the night with phone calls its not worth their time. YMMV.

As far as not billing at all thats just money left on the table. We are looking at the billing for all of our units by RVUs as we ramp up our NPP staff (20 in the last year). Its a considerable amount over what the physicians were billing.

David Carpenter, PA-C

juan de la cruz, MSN, RN, NP

Specializes in APRN, Adult Critical Care. Has 27 years experience.

I would label the argument that you can't bill E/M in critical care wrong. The problem is that people mistake what CMS means by service when they say critical care service. We use critical care service to mean the people that provide critical care. CMS uses it in a totally different way. When they say service they mean four very specific methods of billing. They are E/M, critical care, procedures, and (in 2005) consultation (which was a separate form of E/M). CMS very deliberately took consults out of shared billing in 2008. They left shared billing intact for E/M. The statement is that the service can be provided in any setting just like critical care. Here is the CMS guidelines for shared billing:

"Hospital Inpatient/Outpatient/Emergency Department Setting.--When a hospital inpatient/hospital

outpatient or emergency department E/M is shared between a physician and an NPP from the same

group practice and the physician provides any face-to-face portion of the E/M encounter with the

patient, the service may be billed under either the physician's or the NPP's UPIN/PIN number.

However, if there was no face-to-face encounter between the patient and the physician (e.g., even if

the physician participated in the service by only reviewing the patient's medical record) then the

service may only be billed under the NPP's UPIN/PIN. Payment will be made at the appropriate

physician fee schedule rate based on the UPIN/PIN entered on the claim."

Here is the AAPA brief on this:

Shared Visit Billing in a Hospital Setting - American Academy of Physician Assistants (AAPA)

Whether shared billing is worth the effort is going to depend on the payor mix and the staffing mix. I also work for a big university hospital with fellows etc. We have five ICUs with around 100 or so beds. One is staffed solely by NPPs and intensivists, three by residents and NPPs and intensivists, and one by residents and specialists. The unit that is staffed solely by NPPs has a lot of observation patients (ie not critically ill but have to be watched closely). They generate a lot of E/M time. They also have more (relatively speaking) NPPs and intensivists. In their model the intensivist goes around and sees all the patients in the AM and discusses their plan. In our model we are expected to move any patients we can out before the intensivist rounds in the afternoon so they don't have to see them. In the first model the 15% probably adds $15k a month or so. In our model we could add another $2-3k per month but that would mean the physician would have to stay another 2 hours later per day. Since they are already there pretty late most days and up most of the night with phone calls its not worth their time. YMMV.

As far as not billing at all thats just money left on the table. We are looking at the billing for all of our units by RVUs as we ramp up our NPP staff (20 in the last year). Its a considerable amount over what the physicians were billing.

David Carpenter, PA-C

Good to hear your perspective. I actually had the impression that shared billing was allowed in critical care (at least in my past job) but now I'm getting mixed information in this current job. I also agree that allowing NPP's to bill does increase revenue. It's an agenda some NPP's here are pushing for but in a cautious manner obviously.