Collaborative Care Models Pennsylvania Chapter American College of Cardiology April 28, 2006 Michelle Ashby, CRNP Pau

1. Collaborative Care ModelsPennsylvania ChapterAmerican College of CardiologyApril 28, 2006Michelle Ashby, CRNPPaul Casale, MDThe Heart GroupLancaster, PA

2. Objectives: 1. Describe several practice models for cardiology utilizing nurse practitioners and physician assistants. 2. Identify 4 benefits of utilizing NPs and/or PAs in a cardiology practice.  3. Briefly discuss 3 methods to bill for NP and PA services. 

3. Employment Models Private Practice University/Hospital “Lease Agreements”

4. Office “Risk factor” clinics Heart failure clinic EP clinic Anticoagulation clinic Post-discharge visits Stress tests Independent schedules “Tag Team” approach

5. Hospital Admissions Consults Rounds Nursing calls Procedures On Call coverage

6. Supervision of Diagnostic Tests NP/PA may perform diagnostic tests, but may not supervise someone else (tech/nurse) performing the diagnostic test "Limited License Practitioners: NP, CNS, and PA are not defined as physicians. Therefore, they may not function as supervision physician under the diagnostic tests benefit. However, when performing diagnostic tests, they are not required to meet the physician supervision requirements defined here. Instead, they may perform diagnostic tests pursuant to State scope of practice laws and under the applicable State requirements for physician supervision or collaboration.” www.hgsa.com/professionals/refman/appendix-l-m.html

7. Supervision of Diagnostic Tests General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician. (Level 1)

8. Supervision of Diagnostic Tests Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. (Level 2) Personal supervision means a physician must be in attendance in the room during the performance of the procedure. (Level 3)

9. “ Incident to” Billing another providers service using the physician’s billing number at 100% reimbursement. Applies to office setting, not hospital Physician must personally perform the initial service and remain actively involved in the course of treatment Physician must be present in the office suite Can also bill incident to NP/PA service

10. “ Incident to” When does the NP/PA need to bill directly? (with NP/PA’s billing number, 85%reimbursement) New patients Established patients with new problems Physician is not physically present in the office suite www.cms.hhs.gov/MLNMattersArticles/downloads/SE0441.pdf www.hgsa.com/newsroom/news09162002.shtml

11. Shared Visits Hospital inpatient, hospital outpatient or emergency department E/M service Shared between a physician and an NPP from the same group practice Physician provides any face-to-face portion of the E/M encounter with the patient

12. Shared Visits Service may be billed under either the physician's or the non-physician's PIN number  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 non-physician's PIN (at 85%) 

13. Shared Visits The service must be within the scope of practice for the NPP The service must be “reasonable and necessary” as defined by Title XVIII of the Social Security Act, Section 1862(a)(1)(A) The NPP service and the physician service may occur jointly or at independent times on the same calendar day

14. Shared Visits The total documentation by both the NPP and the physician should support the level of service reported Non-physician practitioner (NPP) is a nurse practitioner, clinical nurse specialist, certified nurse midwife, or a physician assistant – however CNS has no scope of practice in Pennsylvania

15.  NPP sees a hospital inpatient at one time and documents his/her service.  Physician, later in the day, has a face-to-face encounter with the patient, personally verifies one (or more) element(s) of the NPP encounter, and documents his/her participation in the medical record.  Either the physician or NPP may report the service based on the combined documentation.

16. Documentation of Shared Visits Acceptable documentation from physician: “Seen and agree.  Less abdominal pain today.  Legible physician signature.”  “Agree with above.  Lungs clear.  Legible physician signature.” Unacceptable documentation:  “Noted.  Proceed with endoscopy.  Legible physician signature.”  (This documentation fails to establish the face-to-face encounter by the physician with the patient.)

17. Shared Visits Frequently Asked Questions Q:  Can I apply the shared/split billing rules to medical students?  Residents?  Nurses?  Other personnel in my employ or under my supervision?  A:  No.  The shared/split billing rules apply only to NPPs.  Q:  Can a procedure be billed using the shared/split billing rules? A:  No.  Only evaluation and management services (CPT codes 99201-99399) may be billed using the shared/split billing mechanism.

18. Shared Visits Frequently Asked Questions (cont’d) Q:  Can the NPP and the physician bill for a time-based E/M service based on their pooled time? A:  Yes.  The NPP and the physician may pool their non-overlapping time for the time-based codes (e.g. discharge day management, CPT 99238-99239).  This, however, does not include critical care services at this time. Q:  Can the NPP and the physician bill for a shared/split E/M service based on their pooled time dedicated to counseling/coordinating care?  A:  Yes.  The NPP and the physician may pool their non-overlapping time spent counseling/coordinating care.

19. Shared Visits Frequently Asked Questions (cont’d) Q:  Does the NPP have to be in my direct employ? A:  No.  For any setting, the NPP may be directly employed by the physician, physician  group, or entity that employs the physician(s). The NPP services may also be leased by the physician, physician group, or entity that employs the physician(s) or an independent contractor. Q:  Must the NPP be in my provider group?    A:  Yes.  Regardless of the employment arrangement (e.g., W-2 employee, leased or independent contractor) between the NPP and the physician, physician group, or entity that employs the physician(s), the NPP’s provider number must be linked to provider group of the physician rendering the shared/split service.

20. Consultations Effective 1/1/06 consultations cannot be billed as a shared/split visit The intent of a consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional's knowledge. Consultations may be billed based on time if the counseling/coordination of care constitutes more than 50 percent of the face-to-face encounter  http://www.hgsa.com/professionals/lcd/c2h.html

21. National Provider Identifier (NPI) Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the Secretary of Health and Human Services adopt a standard unique health identifier for health care providers NPI remains with the provider regardless of job or location changes In use by May 23, 2007, but small health plans have until May 23, 2008 To apply: https://nppes.cms.hhs.gov

22. Medicaid Medicaid will now credential all NPs, regardless of specialty MA Bulletin (12/16/05) Clarification of Enrollment Policy for CRNPs http://www.dpw.state.pa.us/Business/BulletinManageDir/003673169.aspx?BulletinId=1133

23. Professional Resources Pennsylvania Coalition of Nurse Practitioners (PCNP) www.pacnp.org American College of Nurse Practitioners (ACNP) www.acnpweb.org American Academy of Nurse Practitioners (AANP) www.aanp.org Pennsylvania Society of Physician Assistants (PSPA) www.pspa.net American Academy of Physician Assistants (AAPA) www.aapa.org

24. 217 Harrisburg Ave., Suite 200Lancaster, PA 17603 Michelle Ashby, CRNPph (717) 390-4676ashbynp@comcast.net Paul Casale, MD ph (717) 397-5484