5 hours ago · The consultant should report this initial service as an initial inpatient consultation code (99251-99255), with the level determined by the medical necessity of the visit and supported by the documentation guidelines. The initial provider requesting the service will use the consultant’s findings in the ongoing care of the patient. >> Go To The Portal
Only one initial inpatient consultation can be reported during a single episode of care.
Although there is a growing body of evidence from health services research that suggests that NPs can deliver certain elements of primary care as well as physicians, there is a dearth of rigorous research that isolates the effect of NP scope of practice rules on health care quality, cost, and access at the state level.10
Due to the small number of included studies we cannot conclude that the quality of care provided by APRNs does or does not vary by setting of practice (eg, hospital vs free-standing clinics, multispecialty vs solo practice, or differing case mix managed by a CRNA). KEY QUESTION 3.
Under the Hospital Inpatient Quality Reporting Program, CMS collects quality data from hospitals paid under the Inpatient Prospective Payment System, with the goal of driving quality improvement through measurement and transparency by publicly displaying data to help consumers make more informed decisions about their health care.
In reduced-authority states, NPs can diagnose and treat patients, but they need physician oversight to prescribe medications. For NPs who work in restricted states, they cannot prescribe, diagnose, or treat patients without physician oversight.
Nurse Practitioner Duties & ResponsibilitiesConduct health assessments including recording complete medical and psychosocial history.Record symptoms.Physically examine patients.Make diagnoses.Develop a treatment plan that may include medication and other therapies.More items...•
APRNs provide patient assessments, diagnose diseases and conditions, order tests, prescribe medications and direct patient care. Some states allow APRNs to dispense medications under certain conditions and others permit APRNs to provide drug samples to patients.
Roles of a Nurse Practitioner Working directly with patients, NPs can diagnose and manage most common and many chronic illnesses. They are authorized to perform physical examinations, order and interpret diagnostic tests, provide counseling and education, and write prescriptions.
Broadly speaking, NPs are trained to assess, diagnose, order, and interpret medical tests, prescribe medications, and collaborate in the care of patients. The scope of practice for a nurse practitioner varies from state to state, and sometimes even from hospital to hospital.
Nurse Practitioner Responsibilities: Performing physical exams and patient observations. Recording patients' medical histories and symptoms. Creating patient care plans and contributing to existing ones. Ordering, administering, and analyzing diagnostic tests.
NP practice includes, but is not limited to, assessment; ordering, performing, supervising and interpreting diagnostic and laboratory tests; making diagnoses; initiating and managing treatment including prescribing medication and non-pharmacologic treatments; coordinating care; counseling; and educating patients and ...
There are four types of roles for an Advanced Practice Registered Nurse (APRN): clinical nurse specialists, certified registered nurse anesthetists, certified nurse practitioners, and certified nurse midwives. All of these roles require a master's degree in addition to appropriate certification and licensing.
Nurse practitioners who work at a level below an ANP (ie at senior practitioner level on the Career Framework) are usually termed nurse practitioners and have a more limited scope of practice. In this article, an ANP is defined as a nurse practitioner practising at an 'advanced practice' level.
Only one initial inpatient consultation can be reported during a single episode of care. If the consultant is called back for a follow-up service during the same hospitalization or the consultant continues to follow a patient for an identified problem, a consultation code is not appropriate and the follow-up service or subsequent visit should be ...
The consultant should report this initial service as an initial inpatient consultation code (99251-99255), with the level determined by the medical necessity of the visit and supported by the documentation guidelines.
Editor’s note: In the calendar year (CY) 2010 MPFS final rule with comment period (CMS-1413- FC), the Centers for Medicare & Medicaid Services (CMS) eliminated the payment of all CPT® consultation codes (inpatient and office/outpatient codes) for various places of service except for telehealth consultation HCPCS Level II G-codes.
Documentation guidelines for a consultation service require that all three key components (history, examination, and medical decision-making) be met to support the correct level of consultation. Note: the only variant between a level four and a level five consultation is the medical decision-making component.
The intent of a consultation is for another source to request the physician or NPP’s advice, opinion, guidance, input, or help in making recommendations for evaluation or treatment of a patient as their expertise in a medical area is beyond that of the requestor.
There must be a request from another health care provider documented in the common medical record which indicates the consultant is expected to provide advice and/or opinion. The request must include the need for consultation.
A consultant may initiate diagnostic and/or therapeutic services at the time of the initial service if they are medically necessary and does not limit the appropriateness of billing a consultation code. A consultation may be reported if the referring physician does not transfer the responsibility of the patient’s care of the specified problem to the receiving physician until after the consultation is complete.
This meta-analysis included 25 articles, relating to 16 studies, comparing outcomes of primary care nurses (nurses, NPs, clinical nurse specialists or other APRNs) and physicians. The quality of care provided by nurses was as high as that of the physicians. Overall, health outcomes and outcomes such as resource utilization and cost were equivalent for nurses and physicians. The satisfaction level was higher for nurses. Studies included a range of care delivery models, with nurses providing first contact, ongoing care and urgent care for many of the patient cohorts.
These included: amount/depth of discussion regarding child health care, preventative health and wellness; amount of advice, therapeutic listening and support offered to patients; completeness of history and follow up on history findings; completeness of physical examination and interviewing skills; and patient knowledge of the management plan given to them by the provider.
Evidence regarding the impact of NPs compared to MDs on health care quality, safety and effectiveness was systematically reviewed. Data from 37 of 27,993 articles published from 1990–2009 were summarized into 11 aggregated outcomes. Outcomes for NPs compared to MDs are comparable or better for all 11 outcomes reviewed. A high level of evidence indicated better serum lipid levels in patients cared for by NPs in primary care settings. A high level of evidence also indicated that patient outcomes on satisfaction with care, health status, functional status, number of emergency department visits and hospitalizations, blood glucose, blood pressure and mortality are similar for NPs and MDs.
This meta-analysis of studies comparing the quality of primary care services of physicians and NPs demonstrates the role NPs play in reinventing how primary care is delivered. The authors found that comparable outcomes are obtained by both providers, with NPs performing better in terms of time spent consulting with the patient, patient follow ups and patient satisfaction.
Using data from a national sample of 64,354 Medicare beneficiaries, a retrospective cohort study was used to compare process and cost of care for patients with diabetes mellitus in 2009 who had received primary care from an NP or primary care physician. The authors conclude that low-density lipoprotein cholesterol testing and nephropathy monitoring rates were similar between both providers. Between the two provider types, there was no statistically significant difference in adjusted Medicare spending.
A meta-analysis of 38 studies, comparing a total of 33 patient outcomes of NPs with those of physicians, demonstrated that NP outcomes were equivalent to or greater than those of physicians. NP patients had higher levels of compliance with recommendations in studies where provider assignments were randomized and when other means to control patient risks were used. Patient satisfaction and the resolution of pathological conditions were greatest for NPs. NP and physician outcomes were equivalent on all other outcomes.
The chosen unit for randomization was families; 1,598 families were eligible for the trial, and two-thirds were assigned to standard care with a family physician and the other third to care with NPs. A household survey was conducted before and after the experimental period to collect health status and medical services utilization. During this one-year period, management of preselected indicator conditions and drug prescriptions were assessed for quality of care.
Medical licensing is a state function and APRN scope-of-practice (SOP) laws vary from state to state. 5In 16 states, APRNs have the authority to practice without a written agreement with a supervising physician, 9 states require physician involvement to prescribe but not to diagnose and treat, and in 24 states physician oversight is required to prescribe, diagnose, and treat.6The definition of “oversight,” however, varies by state, and most states allow collaboration or supervision to occur remotely.7There is also variation in SOP laws regarding APRNs' authority to supervise clinical staff. For example, one article notes a requirement in sections 2069–71 of the California Business and Professions Code that doctors and selected other professions— but not registered nurses—may supervise California medical assistants.8
Today, most NPs practice in primary care. Autonomy or independence has always been central to the concept of a nurse practitioner as a primary care provider.2The National Council of State Boards of Nursing defines “independence” as practicing with “no requirement for a written collaborative agreement, no supervision, [and] no conditions for practice.”3Although the authority to diagnose and prescribe are the most frequently mentioned aspects of independence, the concept encompasses other dimensions including entry into practice; authority to bill for services independently; access to diagnostic services and hospital admitting privileges; and recognition as primary care providers.4
In 2009, the ESP Coordinating Center was created to expand the capacity of QUERI Central Office and the 4 ESP sites by developing and maintaining program processes. In addition, the Center established a Steering Committee comprised of QUERI field-based investigators, VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service Networks (VISN) Clinical Management Officers. The Steering Committee provides program oversight, guides strategic planning, coordinates dissemination activities, and develops collaborations with VA leadership to identify new ESP topics of importance to Veterans and the VA healthcare system.
QUERI provides funding for 4 ESP Centers and each Center has an active VA affiliation. The ESP Centers generate evidence syntheses on important clinical practice topics, and these reports help:
Recent publications promoting over-riding state scope-of-practice laws argue that a large body of evidence shows APRNs working independently provide the same quality of care as medical doctors. We found scarce long-term evidence to justify this position.
The National Governors Association10and the Institute of Medicine (IOM)11have criticized variation in SOP regulations among the states, and both argue that nurses should be able to practice to the “full extent of their education and training” in order to adapt to the changing health care system after the implementation of the Affordable Care Act (ACA), which authorizes nurse-managed health clinics and other innovations. In March, 2014, a report from the Federal Trade Commission, relying in large part on the IOM report, argued that physician supervision or collaborative practice agreement requirements “may sometimes restrict competition unnecessarily, which can be detrimental to health care consumers and have broader public health consequence,” that is, “decreased access to health care services, higher health care costs, reduced quality of care, and less innovation in health care delivery.”12In the context of the ACA, one emergent issue is whether some patient care teams should be led by a nurse practitioner instead of only a medical doctor. Other advocates for change argue that, nationally, removing restrictions on NP practice would improve access to primary care and allow NPs to emerge as leaders of the integrated teams that are an important component of new models for delivering primary care.8,13,14
Strong conclusions or policy changes relating to extension of autonomous APRN practice cannot be based solely on the evidence reviewed here. Although no differences in 4 outcome measures (health status, quality of life, mortality, hospitalizations) were detected, the evidence cannot rule out such differences. Published evidence about performance measures, satisfaction, resource use, and considerations of access to care—as well as the track record of VA facilities that use this model—should be considered.
If an NP sees patient in the morning and documents that visit, then the physician follows with a face-to-face later the same day , the physician’s claim should be submitted with HCPCS modifier AI.
The principal physician of record is identified in Medicare as the physician who oversees the patient’s care from other physicians who may be furnishing specialty care. The principal physician of record shall append modifier “-AI” (Principal Physician of Record), in addition to the E/M code.
Nurse Practitioners, unless authorized by their state regulations, should not submit claims for inpatient hospital admissions (CPT Codes 99221 – 99223: Initial Hospital Care, New or Established Patient).
Inpatient consultation codes are reported once per hospitalization. If reported more frequently, all claims within the same hospitalization subsequently reported with codes 99251-99255 are denied. This happens even when the consultant signs off and is re-consulted for a different problem during the same hospitalization.
Inpatient consultation (99251-99255) for services provided to an inpatient (acute care, inpatient rehabilitation, inpatient psychiatric, long-term acute care, or skilled nursing); or
Physicians typically spend 80 minutes at the bedside and on the patient’s hospital floor or unit. 99255: Inpatient consultation, which requires these three key components: A comprehensive history; A comprehensive examination; and. Medical decision-making of high complexity.
Report: After the patient’s assessment, the consultant documents the service and prepares a written report for the requesting provider, which includes the written request, consultation evaluation, findings, and recommendations.
Reason and request: Consultants (physicians or qualified non-physician providers) are asked to give an opinion or recommendation, a suggestion, direction, or counsel in the treatment of a patient’s condition because the consultant has expertise in a specific medical area beyond the requesting professional’s knowledge.
It is appropriate for the consultant to initiate diagnostic services and treatment at the initial consultation service or at a subsequent visit, yet still qualify as a consult. In the inpatient setting, it is acceptable for the consultant’s report to appear as an entry in the shared medical record without need to forward a separate document to the requesting provider.
The request must be documented in the patient’s medical record. The initial request may be a verbal interaction between the requesting provider and the consulting physician; however, when this occurs, the verbal conversation must be documented by both the consultant (in the progress note) and the requesting provider (in the plan of care or as a written order). Standing orders for consultation are prohibited. Clearly document the reason for the service: the patient’s condition, sign, or symptoms that prompted the consult request, ensuring the medical necessity of the service.
A request (verbal or written) from the referring physician. The specific opinion or recommendations of the consulting physician. A written report of each service performed or ordered on the advice of the consulting physician. The medical expertise requested is beyond the specialty of the requesting physician.
The correct inpatient consultation codes for a first evaluation are 99221-99223. These codes are used for the inpatient History and Physical (H & P), as well as any specialty consultation (limited to one visit from each specialty). In the past, the codes 99221-99223 were used only for the admitting physicians, and the codes 99251-99255 were designated for consulting physicians. The consulting physician codes were dropped from Medicare guidelines due to discrepancies in paid consulting fees and the proper criteria required for those services. The new guidelines require consulting providers also to use 99221-99223.
No matter whether billing for Medicare or a non-Medicare provider, only one inpatient initial code can be billed for each specialty. Additional submissions will be denied. Subsequent hospital visits should be coded using 99231-99233 (not discussed explicitly in this writing).
All services performed in an office and the resulting hospital admission are reflected (i.e., admission following any evaluation and management (E/M) services received by the patient in an office, emergency room, or nursing facility). If these services are on the same date as admission, they are considered part of the initial hospital care.
Second, the old initial consultation codes (99251-99255) are no longer recognized by Medicare Part B, although many non-Medicare providers still use them if ...
In most outpatient settings, the consulting physician’s report (like the consult request and reason) is a separate document sent from one physician to another. In the emergency department (ED) or other outpatient setting in which the medical record is shared between the requesting and consulting physicians (such as a large, ...
Because same-specialty/practice consultations provide an opportunity for abuse, requesting physicians should clarify in the documentation that the same-specialty/practice consulting physician truly has a skill set the requester does not have.
CPT ® defines a consultation as “a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.”. To substantiate a consultation service, documentation must include three elements: a request, a reason, and a report.
In this case, the orthopedist would not report a consult upon seeing the patient because the ED physician isn’t really seeking the orthopedist’s advice or opinion.
The report is not a thank you note to the requesting physician for referring the patient, nor is it a courtesy copy of the history and physical. Rather, the report provides instruction to allow the requesting physician to continue treating the patient.
Medicare will not recognize modifier 32 for payment, nor will it pay for a second opinion evaluation to satisfy a third-party payer requirement (Medicare Claims Processing Manual, chapter 12, section 30.6.10.D).
A3. No. CMS only pays for medically necessary face-to-face visits by the physician or NPP with the resident. Since the NPP is performing the medically necessary visit, the NPP would bill for the visit.
A8. NPPs may not sign initial orders for an SNF resident. However, they may write initial orders for a resident (only) when they review those orders with the attending physician in person or via telephone conversation and have the orders signed by the physician.
How do you bill a consult if a procedure is rendered on the same date? In this situation, you would typically modify the consultation service code, attaching the -25 modifier to indicate a distinct and separate service If, however, the patient had major surgery “which comes with a 90-day global follow-up period “ on the same date, attach a -57 modifier to your consultation code.
Those “r’s” stand for request, rendering and replying. Let’s take a look.
Here’s another situation that hospitalists run into: An ED physician calls for a “consultation” to decide if a patient should be admitted. According to CPT guidelines, that gives you a request and the requesting physician’s name. But if you do admit the patient, you would bill that encounter not with a consultation code, but with an initial hospital care code.
Stating that a patient was “referred” means that care was transferred from a referring physician, not that a consultation request was made.
Subsequent visits are reimbursed at much lower rates than consults. The same holds true for outpatient consultation codes. Any documentation oversight could lead to a consult being billed as a new outpatient visit, which carries a much lower work value and reimbursement.
Documenting “internal medicine” or “blue team” when billing a consult will not suffice. A consultation can’t be initiated by a patient or family member. (Consults can, however, be initiated by a therapist, social worker, lawyer or insurance company.) If a social worker or therapist asks for your clinical opinion, ...
Requests, rendering and replies. In hospitals, doctors can make a request for a consultation via a note in the patient’s chart. But keep in mind that coders rarely have the opportunity to see the entire chart when billing for a physician’s service.