Pennsylvania NPs and stress tests

ANPFNPGNP · Sep 30, 2008

Can someone help shed some light on this situation. I work for a cardiologist in Pennsylvania and he does stress tests in his office (adenosine, dobutamine and exercise). Can an NP be the "licensed practitioner" supervising the tests or does it have to be the physician. We would like to be able to have the doc go to the hospital and have me be in the office while the tests are being performed (after all, they can bring in more $$$ per day than me making rounds). But CMS isn't giving us any direction one way or the other except to say, check the scope of practice. Well, the scope of practice doesn't specifically state everything an NP can and can not do so where does that leave us? I am wondering if there are any NPs in Pennsylvania that are the only licensed person in the building while the tests are being run. Also, as I am somewhat new the cardiology, why the fuss? Thanks

I can't imagine why you can't supervise the tests. I would be surprised to hear that you couldn't in any state.

allnurses Guide · Oct 1, 2008

Who's making a fuss?

Another recent thread with some info, although this is asking about RNs: https://allnurses.com/forums/f8/can-rns-conduct-cardiac-stress-tests-325493.html

core0 · Oct 1, 2008

Can someone help shed some light on this situation. I work for a cardiologist in Pennsylvania and he does stress tests in his office (adenosine, dobutamine and exercise). Can an NP be the "licensed practitioner" supervising the tests or does it have to be the physician. We would like to be able to have the doc go to the hospital and have me be in the office while the tests are being performed (after all, they can bring in more $$$ per day than me making rounds). But CMS isn't giving us any direction one way or the other except to say, check the scope of practice. Well, the scope of practice doesn't specifically state everything an NP can and can not do so where does that leave us? I am wondering if there are any NPs in Pennsylvania that are the only licensed person in the building while the tests are being run. Also, as I am somewhat new the cardiology, why the fuss? Thanks

Two different questions. One is does your state scope of practice permit NPs to do stress tests. That can only be answered by your board of nursing.

The second question is, can an NP bill Medicare for a stress test. The article referred to in the other thread showed that stress tests required personal supervision (the physician must be present in the room). This was apparently superseded in 2000 and the new requirements were that stress tests required direct supervision (physician immediately available and present in the suite).

This is from a carrier that covers PA among others:

http://www.carefirst.com/pages/mdmedicare/pdf/Cardiovascular%20Stress%20Testing%2000-04.pdf

The only article that I could find that dealt with this:

http://www.terryfletcher.net/g_codes.php

If I understand this right (and I admit this is not my area of expertise) there are four codes associated with this;

93015-(cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report)
93016-(...; physician supervision only, without interpretation and report)
93017-(...; tracing only, without interpretation and report)
93018-(...; interpretation and report only)

If the physician did the entire procedure themselves (personal supervision) and the interpretation they bill 93015 which is the global fee.

If the NPP does the test and the physician giving direct supervision the NPP bills 93017 and the physician bills 93016 and 93018. Thats my best guess anyway.

So the answer to your question is that you cannot bill for a stress test unless the physician is physically present. The reason for this is discussed here:

http://www.circ.ahajournals.org/cgi/content/full/102/14/1726

This also deals with liability and competence. While separate from this discussion the number of stress tests done should be discussed with the physician as the article above definitely addresses liability.

Interestingly NPs and PAs do stress tests in the hospital frequently and can bill for them under different rules. There is no clear medicare guidance on why there are different standards except references to greater resources in a hospital.

David Carpenter, PA-C

JEKA · Oct 1, 2008

Thank you all for the great replies. The "fuss" I am referring to has to do with CMS not directly stating "yes" and the board of nursing not specifically stating that the NP can or can't do them. My office manager is leary about having me be the only "licensed" professional in the building while they're being done (for legal reasons of course). The Pennsylvania board of nursing isn't really giving her any direction either. They just keep saying "refer to her scope of practice", which doesn't say much of anything. David, you are such a great resource. Thank you for the guidance. I haven't gotten to the articles yet but I am looking forward to it.

Thanks again to everyone. I will keep you all updated on how this progresses.

ANPFNPGNP · Oct 1, 2008

Two different questions. One is does your state scope of practice permit NPs to do stress tests. That can only be answered by your board of nursing.
The second question is, can an NP bill Medicare for a stress test. The article referred to in the other thread showed that stress tests required personal supervision (the physician must be present in the room). This was apparently superseded in 2000 and the new requirements were that stress tests required direct supervision (physician immediately available and present in the suite).
This is from a carrier that covers PA among others:
http://www.carefirst.com/pages/mdmedicare/pdf/Cardiovascular%20Stress%20Testing%2000-04.pdf
The only article that I could find that dealt with this:
http://www.terryfletcher.net/g_codes.php
If I understand this right (and I admit this is not my area of expertise) there are four codes associated with this;
93015-(cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report)
93016-(...; physician supervision only, without interpretation and report)
93017-(...; tracing only, without interpretation and report)
93018-(...; interpretation and report only)
If the physician did the entire procedure themselves (personal supervision) and the interpretation they bill 93015 which is the global fee.
If the NPP does the test and the physician giving direct supervision the NPP bills 93017 and the physician bills 93016 and 93018. Thats my best guess anyway.
So the answer to your question is that you cannot bill for a stress test unless the physician is physically present. The reason for this is discussed here:
http://www.circ.ahajournals.org/cgi/content/full/102/14/1726
This also deals with liability and competence. While separate from this discussion the number of stress tests done should be discussed with the physician as the article above definitely addresses liability.
Interestingly NPs and PAs do stress tests in the hospital frequently and can bill for them under different rules. There is no clear medicare guidance on why there are different standards except references to greater resources in a hospital.
David Carpenter, PA-C

David -

Can a physician bill at the doctor rate when a midlevel sees a Medicare patient, even though the physician doesn't see the patient? I thought we could bill at the doctor rate as long as the doctor was in the office. My friend said that we could only bill at the doctor rate if the physician saw the patient too.

jer_sd · Oct 1, 2008

David -
Can a physician bill at the doctor rate when a midlevel sees a Medicare patient, even though the physician doesn't see the patient? I thought we could bill at the doctor rate as long as the doctor was in the office. My friend said that we could only bill at the doctor rate if the physician saw the patient too.

A basic answer, it looks like you are refering to incident to billing,

As long as a physician sees the patient and established a plan of care, the employees of the physicain can see the patient for continued care, as long as there are no new conditions treated and bill incident to the physician at 100% of payment. The physician must be in the facility, and this can not be done for inpatients.

If the physician is not in the facility, or is there is a new concern addressed then it should be billed under the NP/PA NPI for 85% reinbursement. If an employee of the NP/PA sees the patient and the NP is in the office then it can be billed incident to the NP/PA at the 85% rate ect.....

Jeremy

core0 · Oct 2, 2008

A basic answer, it looks like you are refering to incident to billing,
As long as a physician sees the patient and established a plan of care, the employees of the physicain can see the patient for continued care, as long as there are no new conditions treated and bill incident to the physician at 100% of payment. The physician must be in the facility, and this can not be done for inpatients.
If the physician is not in the facility, or is there is a new concern addressed then it should be billed under the NP/PA NPI for 85% reinbursement. If an employee of the NP/PA sees the patient and the NP is in the office then it can be billed incident to the NP/PA at the 85% rate ect.....
Jeremy

This is the basics for incident to. The devil is in the details. Here are two articles on incident-to.

http://www.medscape.com/viewarticle/422935_4

http://www.aafp.org/fpm/20011100/23thei.html

The first by Carolyn Bupert is probably the best. The AAFP article differs in that it claims that the physician only has to see the patient for the initial problem. Most coding classes and national carriers state that the physician has to see the patient for each new problem but that continuing care can be done incident to. It really depends on how you define continuing care. For example in cardiology you see a patient post MI. The physician sees the patient does all the elements of E/M coding and puts out a plan of care. The NP (or PA) can then follow the patient and even address issues that arise out of the MI such as HTN or dyslipedemia. On the other hand if the patient comes in with a new cardiac complaint (say CHF) then the NP could do the E/M encounter and bill at 85% of the physician rate or the physician could do the E/M encounter and bill under the physician rate. The NP then could follow the patient for MI and CHF. Now you could argue that the CHF is part of the MI and continue to manage it that way. The only issue is that if you look at the description of penalties here, its easy to see how you can be on the hook for a lot of money.

Notice it says that the physician must do the E/M portion. Its not enough that the physician sees the patient they must do the physical exam, ROS, assessment and plan. The other issue is the physician must be available and in the suite. Note for clinics attached to a hospital being in the hospital does not count.

It works well in specialty practice, less well in primary care. For example if you are following a patient for HTN and they come in with a cold, is it worth pulling the physician away from their schedule in order to see someone with a cold? Most of the time its more productive to just take the 85% and be done with it. Because its fairly easy to get crossways with incident-to rules a lot of practices don't bother.

David Carpenter, PA-C

core0 · Oct 2, 2008

Thank you all for the great replies. The "fuss" I am referring to has to do with CMS not directly stating "yes" and the board of nursing not specifically stating that the NP can or can't do them. My office manager is leary about having me be the only "licensed" professional in the building while they're being done (for legal reasons of course). The Pennsylvania board of nursing isn't really giving her any direction either. They just keep saying "refer to her scope of practice", which doesn't say much of anything. David, you are such a great resource. Thank you for the guidance. I haven't gotten to the articles yet but I am looking forward to it.
Thanks again to everyone. I will keep you all updated on how this progresses.

I think your office manager is wise (probably the first time I've ever said that). I trained in PA and after leaving never intend to return (except for the odd vacation). The liability situation there is a nightmare. If you are the only one in the building and something bad happens you are essentially done (in my opinion). There is Medicare guidance saying that this is a high risk test and should only be done under direct supervision of a physician. I asked around on this and this in one of the few places where Medicare means a physician not a physician or NPP. Also there is guidance from ACC and AHA that this should be done under direct supervision. Add in the general PA propensity to give large awards to "deserving" plaintiffs and its a nightmare. Even if you could legally could do this in PA its a very bad idea.

David Carpenter, PA-C

ANPFNPGNP · Oct 2, 2008

It works well in specialty practice, less well in primary care. For example if you are following a patient for HTN and they come in with a cold, is it worth pulling the physician away from their schedule in order to see someone with a cold? Most of the time its more productive to just take the 85% and be done with it. Because its fairly easy to get crossways with incident-to rules a lot of practices don't bother.
David Carpenter, PA-C

You're right, it doesn't work well in primary care. I need to fill my bosses in on this.

allnurses Guide · Oct 3, 2008

To the OP, this came up in an NP class I had today (I'm an ACNP student). My advisor is an ACNP in cardiology in a university hospital. She said that absolutely NPs can do stress tests in PA. Also that basically unless it specifically says that you cannot do a task/procedure, that you can assume you may (following appropriate training obviously).

I believe the list of what you cannot do is at the BON website.

This wouldn't help with billing, unless you billed it under the doc's number.