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NON-PHYSICIAN PROVIDERS
December 1, 2010
Renee H. Martin, Esquire, JD, RN, MSNTsoules, Sweeney, Martin & Orr, LLC
29 Dowlin Forge RoadExton, PA 19341
Tel.: (610) 423-4200Fax: (610) 423-4201
E-mail: [email protected]
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 2
Healthcare Reform
There is currently a 30% shortage of primary care physicians
Patient Protection and Affordable Care Act (“PPACA”) expands the use of non-physician providers (NPPs) to provide care in a less expensive manner
This then expands the availability of physicians to provider services that require a higher level of medical skill
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 3
PPACA & NPPs
Creates additional educational funding for primary care, geriatric and pediatric PAs and CRNPs
Fully integrates the PAs and CRNPS into the Medical Home Demonstration projects
Creates a 5 year 10% incentive payment for primary care services for PAs, CRNPs, and CNMs
Permits PAs to write orders in SNFs
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 4
PPACA & Nurses
Provides federally qualified health centers or nurse-managed health centers 3 year grants to fund recent family nurse practitioner graduates
Provides money for the National Health Service Corps, which offers loan forgiveness to primary care providers, including nurse practitioners, who agree to work in rural & remote areas
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 5
PPACA & Nurses
Provides funding to improve care transitions for high-risk Medicare beneficiaries to reduce costly re-hospitalizations
Increases Medicare payment rate for covered services provided by certified nurse-midwives from 65% of physician fee schedule to 100%
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 6
NPP‘s Legal PerspectivePennsylvania Regulations
Physician Assistants– 49 Pa. Code § 18.121 – § 18.183– Regulated by the State Board of Medicine
Certified Registered Nurse Practitioners– 21 Pa. Code § 21.251 - § 21.321 – Regulated by the State Board of Nursing
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 7
Physician AssistantPennsylvania Law
“A physician assistant shall not perform a medical service without the supervision and personal direction of an approved physician.”
63 P.S. 422.13(d)
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 8
Physician AssistantPennsylvania Regulations
“The physician assistant practices medicine with physician supervision. A physician assistant may perform those duties and responsibilities, including the ordering, prescribing, dispensing, and administration of drugs and medical devices, as well as the ordering, prescribing, and executing of diagnostic and therapeutic medical regimens, as directed by the supervising physician.” 49 Pa. Code § 18.151(a)
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 9
Physician Assistant Supervisor
Primary PA Supervisor– Must be a currently licensed M.D.
Substitute PA Supervisor– Provides supervision in absence of primary
supervisor; may be M.D. or D.O. All supervisors must be registered with &
approved by State Board of Medicine
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 10
Responsibilities of Physician Assistant Supervisor
Prior to start date, primary supervisor must:– Complete application– Register with the Board of Medicine– Enter into Written Agreement with Physician
Assistant– May not permit a PA to engage in conduct
prohibited by law – May not have primary responsibility for more than 2
PAs– Must timely review (within 10 days) PA’s medical
records to ensure they are legally compliant
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 11
Ongoing Responsibilitiesof PA Supervisor– Monitor compliance with Written Agreement and
state laws
– Advise party to Written Agreement of any failure to conform with its standards or with state laws
– Arrange for substitute PA supervisor
– Review progress of patient’s care with patient as needed based on medical condition/prognosis or upon patient’s request
– See each hospitalized patient at least once
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 12
Ongoing Responsibilitiesof PA Supervisor (cont’d.)
– Provide Written Agreement upon request & provide clarification of PA’s orders & prescriptions relayed to other health care providers
– Accept full professional and legal responsibilities
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 13
Physician Assistant Written Agreement
Between Physician Assistant and each Supervising Physician (at least 1 must be a M.D.) & signed by all
Describes manner Physician Assistant will assist each Supervising Physician– List procedures/tasks– Instructions as to how to perform tasks– Medical regimens administered/relayed
List times, manner, place of supervision– Frequency of personal contact with Physician Assistant
Require Supervising Physician to countersign patient record completed by PA within 10 days
List locations and practice settings Approval by Board of Medicine required
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 14
Physician Assistants- ProhibitionsA Physician Assistant may not: Perform a medical service without the supervision of a
PA supervisor Provide medical services except those in Written
Agreement Prescribe/dispense drugs except as described in
Written Agreement Maintain/manage satellite location unless the
maintenance/management is registered with the Board Independently practice or bill patients
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 15
Physician Assistant - Prohibitions (cont’d.)
A Physician Assistant may not:
Independently delegate a task assigned to him by the PA Supervisor to another health care provider
List name independently in a phone directory, etc. that looks like the PA is an independent practitioner
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 16
Physician Assistant Prescribing/Dispensing Drugs
Authorized to prescribe, dispense & administer drugs & therapeutic devices as delegated by Physician Supervisor
May not prescribe/dispense Schedule I controlled substances
May only prescribe/dispense drugs for patients of PA’s Physician Supervisor & as provided by Physician Supervisor’s directions & Written Agreement
May request, receive & sign for professional samples & distribute them to patients
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 17
Physician Assistant Prescribing Authority
May prescribe Schedule II controlled substances for initial therapy:
– up to 72 hour dose– must notify Physician Supervisor ASAP (24 hrs
max) May prescribe Schedule II controlled substances for
ongoing therapy:
– up to a 30 day supply (if approved by Physician Supervisor for ongoing therapy)
Prescription must clearly state whether its initial or ongoing
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 18
Certified Registered Nurse Practitioner (CRNP)
CRNP is an advanced practice registered nurse who holds a graduate degree in nursing (masters or doctoral)
Provides direct primary care or general medical care to patients in a broad range of health services; can diagnose & manage both acute & chronic medical conditions
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 19
CRNP
Unlike a PA, CRNP practices with a high degree of professional autonomy & does not require a delegation from a physician to provide care
NPs can practice on their own in 50% of states Can specialize in everything from family
practice to orthopedics
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 20
CRNP – Pennsylvania Regulations
“A professional nurse licensed in this Commonwealth who is certified by the Board in a specialty area and who, while functioning in the expanded role as a professional nurse, performs acts of medical diagnosis or prescription of medical therapeutic or corrective measures in collaboration with a physician licensed to practice in this Commonwealth.”
49 Pa. Code § 21.251
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 21
CRNP Supervising Requirements
“Collaborating” Physician Physician Licensed in Pennsylvania Either M.D. or D.O. Substitute Physician No Board approval requirements
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 22
CRNPCollaborating Requirements Immediately available: direct communications,
radio, telephone or telecommunications A predetermined plan jointly developed for
emergency services Available on a regular basis for:
– Referrals– Review of standards of medical practice– Establishing/updating standing orders, drug/medical
protocols– Periodic updating in diagnosis and therapeutics– Co-sign records, if needed, for accountability– As stated in the Collaborative Agreement
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 23
CRNP Collaborating/Prescriptive Agreement
Identify CRNP, collaborating & substitute physician Identify areas of practice/categories of drugs Physician attestation that CRNP has
knowledge/experience with drugs Describe circumstances/when physician will see patient Conditions when CRNP may prescribe Schedule II Amount of professional liability insurance maintained
by CRNP No longer need to file with the Board; must be readily
available & provided to anyone who requests it
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 24
CRNP Prescriptive AuthorityCollaborative Agreement
Between a physician & CRNP who will dispense drugs & other medical therapeutic or corrective measures
Prescriptive authority collaborative agreement MUST:– Be in writing– Identify the parties (including the collaborating physician,
CRNP, & at least 1 substitute physician)– Include the CRNP & collaborating physician’s signatures– Include date agreement is signed & its effective date– Identify the specialty in which the CRNP is certified– Identify the category of drugs from which the CRNP may
prescribe or dispense
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 25
CRNP Collaborating Agreement
Prescriptive authority collaborative agreement MUST: (continued)
– Specify the circumstances & how often the collaborating physician will personally see the patient
– Be kept at the primary practice location of the CRNP & a copy filed with the Bureau of Professional & Occupational Affairs
– Be made available for inspection to anyone who requests it, & provided free of charge upon request of a pharmacy/pharmacist
– Be reviewed & updated by the parties at least every 2 yrs– Specify the amount of CRNP’s professional liability insurance
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 26
CRNP Prescribing Authority
May prescribe/dispense if:– Submitted application for prescriptive authority
approval to the Board with the applicable fee
– Completed approved CRNP program– Completed 45 hours of course work in advanced
pharmacology within 5 years of date of application– Completed 16 hours of continuing education in
pharmacology every 2 years therafter– Comply with state standards
Enter into Collaborating Agreement with physician
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 27
CRNP Prescribing Authority (cont’d.)
Effective 12/2009, CRNPs may prescribe Schedule I Narcotics
Restrictions:– Schedule II controlled substance for up to a 30-day
supply as identified in the Collaborative Agreement– Schedule III or IV controlled substance for up to a 90-
day supply as identified in the collaborative agreement– Cannot delegate authority to another provider
Rx includes CRNP’s name, title & certificate; also CRNP’s NPI number when appropriate
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 28
Medicare – Billing Requirements
Covered services are those the PA or
CRNP is legally authorized to perform
under state law
Covered services are now permitted to include CRNP’s supervision of diagnostic tests under the CRNP’s NPI
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 29
Medicare Billing3 Ways to Bill
“Incident to” Independent/Direct (under own NPI) Shared visit (shared/split E/M services)
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 30
Medicare Billing and Reimbursement
“Incident To”: Paid 100% of physician’s fee schedule by billing using the physician’s NPI
Independent/Direct: Paid 85% of physician’s fee schedule by billing using the PA’s or CRNP’s NPI
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 31
“Incident To” Requirements Integral, although incidental, part of the physician’s
professional services Commonly rendered without charge or included in
the physician’s bill Type commonly furnished in physician’s
office/clinic (not hospital) Physician performed the initial service/remains
actively involved in treatment Furnished under physician’s direct personal
supervision Furnished by physician or physician employee
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 32
“Incident To”Direct Personal Supervision:
Office Setting– Present in office suite– Immediately available to assist/direct– Availability by telephone ≠ direct supervision
Group Practice– Any physician member of group can supervise
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 33
“Incident To”
NPP may be employee, leased employee or independent contractor of physician or the legal entity that employs or contracts with the physician.
Sponsoring physician may be employee, leased employee or independent contractor legal entity billing and receiving payment for services.
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 34
Independent/Direct Billing:Physician Assistant
Bill under Physician Assistant’s NPI “General” supervision required (not physically
present) Payment made to Physician Assistant’s
employer Service covered if rendered by a physician Service legally performed by PA in state Directly provided by Physician Assistant Must accept assignment
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 35
Independent/Direct Billing: CRNP
RN/Certified as a NP by recognized certifying body
Possess a master’s or doctoral level in Nursing Services are type considered physician’s services Work in collaboration with a physician (look to
state law) Medicare covered services Direct billing under the CRNP’s NPI and payment
to the CRNP or employer Assignment is mandatory
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 36
Billing of Shared/Split E&M Service Hospital inpatient, outpatient/ER setting E/M Service is a split/shared encounter between
physician and NPP in same group practice Service may be performed at different times of
the day Correlate the 2 visits to a single level of service Physician must perform some portion of the
face-to-face encounter
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 37
Split/Shared E/M Billing
Examples:
Activities of both physician and NPP considered part of the visit
NPP sees hospital patient in AM/Physician sees patient in PM– Bill under either Physician or NPP– Bill combined time for two visits– Physician note must reflect face-to-face encounter
with patient
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 38
Split E/M Billing vs. “Incident To” Billing
Billing Element Incident To Split/Shared E/M
Time of Service Expected that it will pretty much occur all at once
Can be distinct times of day
Place of Service Only in an office setting Anywhere, except office
Supervision Physician must be physically present on the premises
No requirement
Type of Patient Established patient only Any type of patient
Who Can Share? NPPs including techs Specifically NPPs
Type of Service E/Ms, minor office procedures E/M services only
Documentation Straightforward and obvious Must correlate the 2 services to equate to level of service billed
Counting Time Time cannot be pooled Non-overlapping time can be pooled
Physician Involvement
Must be present on the premises, but face-to-face time with the patient is not required
Can be independent of NPP service, but face-to-face with patient is required
Copyright© 2010 Tsoules, Sweeney, Martin & Orr, LLC 39
Medical Assistance
Physician Assistant
May not enroll directly with DPW, follow “incident to”
Will pay for both outpatient and inpatient services performed by Physician Assistant
Bill under Supervising Physician’s provider # Payment made at Physician’s rate Supervising Physician accessible by
telephone/other means (no direct supervision required)