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CE
Medicare Reimbursement for Nurse
Practitioners in Long-term Care
Authors: Stephanie A Lusis, MSN, APRN, BC; Faculty and Disclosures

THIS ACTIVITY HAS EXPIRED

Medicare Reimbursement

Medicare has paid for the services of


nurse practitioners (NPs) and other
midlevel practitioners (MLPs) (eg, CE Information
physician assistants and clinical nurse
specialists [CNSs]) in skilled and Pri
nonskilled nursing facilities for some
time. Effective January 1, 1998,
amendments to the Balanced Budget Act
of 1997 authorized NPs and CNSs to bill
Medicare directly for their services in any
area or setting.[1] The NP role, and
services that are reimbursed within that
role, are influenced by several factors.
Medicare policies are complex and are
modified frequently. Interpretation of
those policies by Part B Carriers varies
from state to state. Individual state laws
have significant differences regarding
scope of NP practice.

In a presentation to NPs regarding coding


for long-term care services, B.J. Girvin-
Reisser, RN, CCS, CCS-P, CPC,
President of Medical Management
Resources, Columbia City, Indiana[2]
emphasized the importance of
understanding all aspects of the billing
process. The NP is responsible for the
accuracy and adherence to regulations for
all billing claims submitted under the
NP's Medicare provider number, even
though the actual completion of forms
may be done by a billing service.

This summary will provide a brief


overview of the process of obtaining
Medicare reimbursement for services
provided by NPs in nursing facilities.
Issues specific to NPs will be addressed,
followed by a brief description of
Medicare guidelines for Evaluation and
Management coding in long-term care
settings. Important aspects of
documentation will be discussed. The
final section will provide a list of
resources to obtain information needed to
ensure accurate submission of claims for
reimbursement. For the purposes of this
paper, the term "nursing facility" will
include both skilled and nonskilled
settings; information applicable to skilled
care recipients will be clearly indicated.

Medicare and Nurse Practitioners

Although most of the information in this


review applies to any Medicare provider
who bills for services in nursing facilities,
certain issues are specific to NPs.
Medicare requires NPs to be certified by a
recognized national certifying body such
as American Nurses Credentialing Center
(ANCC) in order to become a Medicare
provider. An article by Carolyn
Buppert[3] provides a list of other
approved certifying bodies. In addition,
effective January 1, 2003, individuals are
required to possess a Master's degree
from an accredited program.

Covered Services

Medicare covers services an NP is


"legally authorized to perform in
accordance with State law." In addition,
all of the following conditions must be
met. Services must be:

Considered as physician's services


Furnished by a person who meets the
NP qualifications
Furnished in collaboration with an
MD/DO as required by state law
Within the NP's scope of practice as
defined in state law
Not otherwise precluded from
coverage by Medicare law (eg,
routine foot care)

Clearly, Medicare defers to State law with


regard to scope of practice and the nature
of collaboration. State laws regarding
scope of practice vary significantly and
are often vague. They may contain "only
a general statement about responsibilities,
educational requirements and...duties, and
do not explicitly identify services that
are...beyond their scope."[3] In Michigan,
for example, state law provides a
definition of the "practice of nursing" that
serves as the legal scope of practice for
nurses; state law does not delineate a
scope of practice specific to NPs.[4] NPs
must have a thorough understanding of
their state's scope of NP practice and may
obtain this information through the State
Board of Nursing. Contact information is
available online at http://www.ncsbn.org/.

Some states do not require NPs to


practice in collaboration with a physician.
However, the absence of this requirement
by a state does not negate the Medicare
requirement for collaboration.[1]
Medicare defines collaboration as "a
process whereby a NP works with a
physician to deliver health care services
within the scope of the NP's professional
expertise with medical direction and
appropriate supervision as provided for in
jointly developed guidelines or other
mechanisms as defined by Federal
regulation and the law of the state in
which the services are performed."

NPs are encouraged to document their


individual scope of practice, which
reflects specialized education and
training, the individual's knowledge base
and specific role, and the patient
population served. This scope of practice
complements, or may be part of, a
collaborative agreement that outlines the
relationship between the NP and
physician and specifies how issues that
are outside of the NP's scope of practice
are managed.[1]

The NP's Role in Nursing Facilities

Medicare requires that the initial visit


(history and physical), for the purpose of
certifying that the patient requires skilled
care, must be performed by a physician.
An NP may, however, make a "medically
necessary" visit without an initial
physician visit; this could occur when a
newly admitted Medicare patient in a
skilled nursing facility develops a
problem that requires medical evaluation
and intervention, before being seen by the
physician. Girvin-Reisser advised
cautious use of this practice because it
could be viewed as an unnecessary visit
(ie, if the physician were available to see
the patient at the time of admission, only
one visit would have been needed). All
subsequent visits may be performed by an
NP (or other nonphysician), alternating
with the physician.

NPs may perform the initial history and


physical for new long-term care
(nonskilled) admissions. NPs may also
make additional visits, which must be
substantiated based on the patient's need
(ie, acute illness). Medicare provisions
permit 1.5 visits per month; more than
this frequency may invite increased
scrutiny in the form of an audit. Medical
necessity must be documented!

Assuming state law permits, Medicare


allows NPs to help with monitoring and
managing patient conditions, counseling
patients and families, performing certain
procedures, annual physical
examinations, communication with
hospital and community physicians, and
discharge visits.

Incident-to Billing

Medicare operates 2 programs. Part B,


which covers physician services, is the
focus of this paper. Part A covers
hospitalization, skilled nursing facilities,
and some home services. Generally,
Medicare requires that services are billed
under the provider number of the
individual performing the service.
However, certain services and supplies
are covered "incident to" a physician's
professional services. This may include
NP services if they are:

An integral part of the physician's


professional service
Rendered without charge or included
in the physician's bill
Furnished in the physician's
office/clinic
Furnished under physician direct
personal supervision, meaning the
physician is present in the same
office suite and immediately
available[2]

NP services that are billed "incident to" a


physician's service may be reimbursed at
100% of the physician's fee schedule.
However, there is no "incident-to" billing
in the nursing facility because it does not
meet the above criteria. NPs providing
services in a nursing facility must bill
Part B under their own provider number.
Medicare reimburses NPs at a rate of 85%
of the physician fee schedule. The NP
must have a collaborative relationship
with the physician and must not be an
employee of the nursing facility.

Other Billing Issues


During a "Part A" stay in a skilled nursing
facility, certain procedures that may be
performed by an NP may not be
reimbursed by Part B, because they are
"bundled" in the facility's daily rate.
Girvin-Reisser used application of an
Unna boot (a specialized gauze wound
dressing) as an example. The NP can be
reimbursed for such procedures only by
having a contractual agreement with the
facility to be paid directly.

Third-party payers other than Medicare


may have different policies regarding NP
services. Some may not recognize NPs as
covered providers. It is best to obtain, in
writing, the third party payer's policies
regarding coverage of NP services before
submitting a claim.

Coding of Evaluation and Management


(E/M) Services in Nursing Facilities

The following codes are used to report


evaluation and management services for
patients in skilled and long-term care
facilities. Seven elements are used to
define levels of E/M services, although
the first 3 are key components in selecting
the level of service[5]:

History
Physical examination
Medical decision-making
Counseling
Coordination of care
Nature of presenting problem
Time

When visits consist predominantly of


counseling or coordination of care, time is
the key factor determining level of
service.

Comprehensive Nursing Facility


Assessments

Comprehensive Nursing Facility


Assessments are used for new patients
being admitted to a facility (99303), as
well as for established patients at the time
of a yearly history and physical (99301),
or on development of a new problem
resulting in a permanent change of status
(99302-03). All 3 levels of service require
3 key components: history, physical
examination, and medical decision-
making. Counseling and/or coordination
of care are provided as needed depending
on the nature of the problem and the
needs of the patient/family. The 3 levels
differ in the extent of the history and
physical exam components and in the
complexity of medical decision-making
and time spent.

A code of 99301 requires a detailed


interval history, a comprehensive
examination, and medical decision-
making that is straightforward or of low
complexity. Usually, the patient is stable,
recovering, or improving; the provider
reviews and affirms the medical plan and
spends 30 minutes at the bedside and on
the patient's unit.

A code of 99302 requires a detailed


interval history, a comprehensive
examination, and medical decision-
making of moderate to high complexity.
The patient has developed a significant
complication or new problem and has had
a major permanent change in status,
requiring creation of a new medical plan
of care. The provider typically spends 40
minutes at the bedside and on the unit.
This level could be used when an
established patient sustains a new fracture
or cerebrovascular accident, but will not
be hospitalized, and will be managed at
the facility.

A code of 99303 requires a


comprehensive history and examination
and medical decision-making of moderate
to high complexity. This code is used for
initial admission or readmission to the
facility, or for an established patient
developing a new complication causing a
permanent change in status, requiring a
new medical plan of care; the provider
typically spends 50 minutes at the bedside
and on the unit. This level could be used
when taking over care from another
provider and many new problems are
identified and addressed in the medical
plan of care.

Subsequent Nursing Facility Care

Subsequent Nursing Facility Care is


provided to patients in nursing facilities
who have not had a major, permanent
change in status and do not require a
comprehensive assessment. Subsequent
care visits require 2 of the 3 key
components (history, physical
examination, and medical decision-
making.) All levels include reviewing the
medical record, noting changes in the
patient's status, and reviewing orders, as
well as counseling and/or coordination of
care. The 3 levels differ in the extent of
history and physical examination and in
the complexity of medical decision-
making.

A code of 99311 requires any 2 of the 3


elements; a problem-focused interval
history, a problem-focused examination,
and medical decision-making that is
straight-forward or of low complexity.
Usually, the patient is stable, recovering,
or improving; and this applies even if the
patient has several chronic problems. The
provider typically spends 15 minutes at
the bedside and on the patient's unit.

A 99312 code requires any 2 of the 3


elements; an expanded problem-focused
interval history, an expanded problem-
focused examination, and medical
decision-making of moderate complexity.
Usually the patient is responding
inadequately to therapy or has developed
a minor complication; the provider
typically spends 25 minutes at the bedside
and on the patient's unit.

The 99313 code requires 2 of the 3 key


components; a detailed interval history, a
detailed examination, and medical
decision-making of moderate to high
complexity. Usually, the patient has
developed a significant complication or
new problem that does not require a
major change in the medical plan of care;
the provider typically spends 35 minutes
at the bedside and on the unit.

Girvin-Reisser noted that, because of the


high level of complexity implied in the
99301 and 99313 codes, NPs have the
potential to be outside of their scope of
practice if they use these codes. NPs are
advised to clarify usage of these codes
with their state Medicare Part B provider.

The Documentation Guidelines for


Evaluation and Management Services
(1995 or 1997 version), which are
included in the CPT book,[5] provide
definitions and documentation guidelines
for the 3 key components of E/M
services. The Guidelines describe the
types (problem-focused, detailed,
comprehensive) and elements of history,
as well as the types of examination and
required elements for each type. The
Guidelines also describe the 4 levels of
medical decision-making and the 3
elements that determine the level of
complexity. They are:

Number of diagnoses or
management options
Amount and/or complexity of data to
be reviewed
Risk of complications and/or
morbidity or mortality

The Table of Risk, included in the


Guidelines, is helpful in determining
degree of risk and includes clinical
examples. According to Girvin-Reisser,
risk is becoming a more important
determination of medical necessity for
visits to nursing facility patients. The
reader is referred to the Guidelines as this
discussion is beyond the scope of this
article.

Nursing Facility Discharge Services

Nursing Facility Discharge Services are


coded to reflect the total time spent by a
provider for final examination of the
patient, discussion of the nursing facility
stay, counseling and coordination,
discharge instructions and preparation of
discharge records, referrals, and
prescriptions.

A code of 99315 is used for discharge day


management requiring 30 minutes or less.

The 99316 code is used when discharge


day management requires more than 30
minutes; the exact time must be included
in the note/dictation.

Girvin-Reisser noted that the discharge


day is the day of the last provider visit to
the patient, although it may not be on the
day the patient actually leaves the facility.
For example, the patient is leaving on
Saturday; the provider sees the patient on
Friday.

Domiciliary Services

Domiciliary Services are provided in a


facility that provides room, board, and
personal assistance (assisted living) on a
long-term basis. The codes for new
patients (99321, 22, 23) and for
established patients (99331, 32, 33) vary
much like the previously mentioned codes
in extent of history, physical exam, and
complexity.

Documentation Requirements in
Nursing Facilities

Documentation must always support the


level of service, but the volume of
documentation should not determine the
level of service. Adhere to the following
guidelines in documenting nursing facility
visits:

Always begin the note with the chief


complaint. This should be the
primary reason for the visit and may
take the form of a patient symptom,
abnormal lab result, follow-up on a
specific medical diagnosis, etc.
Girvin-Reisser urged caution in
using "asked to see patient for...." as
Medicare may question whether it
was medically necessary for the
patient to be seen by a provider, or
whether the issue could have been
handled by telephone or by the
nursing staff

Document the appropriate type of


history and examination, including
all required components to support
the level of service

Review of test results and reports


from ancillary services, such as
therapies, should be included

Document the patient's progress and


response to treatment as well as
patient noncompliance
Document the plan of care and
expected outcomes; include tests and
medication changes, and the
rationale for these. The complexity
of medical decision-making should
be reflected in the note

Document content of counseling and


coordination, and time spent on these
activities

Sign and date all medical record


entries

Place of Service

Information that must be submitted (or


provided to billing service) accurately
includes place of service (POS) and
diagnoses. POS varies depending on the
type of facility the patient is in. POS
could be a skilled nursing facility (SNF)
when the patient is medically certified for
skilled care under Medicare Part A. An
individual qualifies for skilled care within
30 days of a 3-day (minimum) hospital
stay, and when they have the potential for
improvement with rehabilitation, or the
need for skilled nursing care. Some
hospitals have "swing" beds that are
equivalent to SNF beds and are
sometimes referred to as "transitional"
beds. POS could also be a nonskilled
facility for basic care, or an assisted living
unit for domiciliary care.

Diagnoses

Diagnoses, submitted as ICD-9 codes,


give the reason(s) for the visit, with the
first-listed diagnosis establishing the
medical necessity of the visit. Girvin-
Reisser reported that the "weighted value"
of the diagnosis is now the "driving force
in reimbursement." Weighted value is
determined by the specific complication
and/or manifestation accompanying the
diagnosis. It is important to be as specific
and accurate as possible in selecting the
diagnosis code(s) for the visit.

For example, the diagnosis of diabetes


mellitus is assigned the 3-digit ICD code
of 250.[6] There are at least 9 options for
a fourth digit indicating manifestations,
and 4 more options for a fifth digit
indicating type of diabetes and whether it
is controlled. However, if a patient with
diabetes is seen for a separate problem
such as a urinary tract infection (UTI),
then UTI should be the listed diagnosis,
not diabetes.

Girvin-Reisser reminded attendees of the


importance of accurate reporting because
diagnosis codes are used to:

Collect healthcare data throughout


the world
Track the spread of disease
Collect mortality statistics
Access morbidity rates
Provide a universal language to
describe disease
Drive reimbursement systems
Determine DRG payment rate for
services in hospitals

Learning More About Billing

The Medicare provider, whether NP,


physician, or other recognized category, is
responsible for all billing submitted for
reimbursement, although the actual
coding and completion of the billing form
(HCFA 1500 Form) may be done by a
billing service. The provider, not the
biller, can be sanctioned (prohibited from
billing any government entity) if
submitted billing is found to be inaccurate
or incorrect. Therefore, it is most
important not only to have a reputable,
competent billing service, but, as a
provider, to be familiar with billing
procedures and regulations. This section
will identify several sources of
information that can and should be
consulted in understanding Medicare
reimbursement.

Key References
The Physician's Current Procedural
Terminology (CPT book) provides
definitions and procedures for the use of
E/M codes. It includes 1995/1997
Documentation Guidelines for Evaluation
and Management Services, the Table of
Risk, and time frames for various service
levels. An updated version is available
yearly and must be purchased by the
billing service.

International Classification of
Diseases,9th edition (ICD-9) provides
codes for medical diagnoses (reasons for
visits).

Medicare Carrier's Manual, the "billing


bible," provides operating instructions for
the contractors who administer Part B of
Medicare. The billing service should
accumulate all updates and clarifications
from Medicare, which are in the form of
transmittals and bulletins.

Carriers-Medicare Part B includes


private insurance companies that contract
with the federal government to process
Medicare claims and make payments for
services and supplies covered by Part B.
[1]

The Centers for Medicare and Medicaid


Services (CMS) Web site provides
information on all aspects of the Medicare
program, including a section for questions
on Part B services and updates on
reimbursement policies and procedures.
Girvin-Reisser also noted that the
Freedom of Information section allows
requests for clarification on policies and
interpretations to be submitted
anonymously.

The Federal Register also includes


Medicare updates.

In summary, NPs must be knowledgeable


about state laws regarding scope of
practice, as well as understanding
Medicare policies and procedures, in
order to be certain of receiving the
reimbursement to which they are legally
entitled. NPs provide a valuable service to
residents of nursing facilities, and their
presence is likely to increase as
physicians and payers recognize this
value. As Medicare providers, NPs have
the responsibility of maintaining current
knowledge of rules and regulations
governing their practice and should make
use of the resources listed to fulfill this
responsibility.

References

1. American Medical Directors'


Association (AMDA). Mid-Level
Practitioners in Long Term Care.
2001. Available at:
http://www.amda.com/info/ltc/midlevel.htm
(fee required).
2. Girvin-Reisser BJ. Coding for long
term care. Program and abstracts of
the National Conference of
Gerontological Nurse Practitioners
22nd Annual Conference; September
17-21, 2003; West Palm Beach,
Florida.

3. Buppert C. Billing for nurse


practitioner services: guidelines for
NPs, physicians, employers, and
insurers. Medscape Nurses; 2002.
Available at:
http://www.medscape.com/viewarticle/422935.
Accessed October 16, 2003.

4. Nurse Practitioner Resource


Document available from the
Michigan Nurses' Association.
Available at:
http://www.minurses.org/apn/apn-
npfaq.shtml. Accessed November 4,
2003.

5. American Medical Association.


Physicians' Current Procedural
Terminology 2003. Chicago, Ill:
American Medical Association;
2003.

6. Centers for Disease Control and


Prevention. ICD-9: International
Classification of Diseases, 9th
revision. Hyattsville, Md: Centers
for Disease Control and Prevention;
2001.

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