Finance Chapter 3 Flashcards
When was the start of direct reimbursement for NP services by Medicare and what was it limited to?
1990; limited to NPs in rural areas and SNFs
Medicare amended its reimbursements of APRNs to include _____. when was this?
include all geographical regions including clinical nurse specialist, nurse midwife, and nurse ANESTHETIST services. 1997
Describe INcident-To Versus Direct Billing percentages
If billed directly, NP are reimbursed at 85% of the physician fee schedule.
If billed as incident-to physician billing, then reimbursement is 100%.
Many practices bill NP services as incident-to, making it difficult to calculate the NP contribution
Requirements for Incident-To Billing (7 total)
ALL must be met
- Services provided to Medicare beneficiary
- Services are in “noninstitutional setting” and not in a Federally Qualified Health Center
or Rural Health Center - Must be a follow-up visit with an already established plan of care
- Care must be provided under “direct supervision” of physician
- Physician must “actively” participate in and manage course of treatment
- Both physician and NP must be employed by the same entity
- The service must be of a type usually performed in the office setting and part of the
normal course of treatment
Current Procedural Terminology (CPT)
codes that describe medical, surgical, and diagnostic services
New pt if was not seen within 3 years
- E&M
- The four levels of care present for new and established patients are: straightforward, low, moderate, and high.
- Must include a medically appropriate history and/or examination
The evaluation and management (E&M)
services guidelines, which have seven components (nature of presenting problem, history, physical examination,
medical decision-making, counseling, coordination of care, and time)
A standard language is
used to record and classify care:
- CPT
- E&M
-ICD-10-CM codes
International Statistical Classification of Diseases and Related Health
Problems (ICD) codes identify the disease, sign, symptom, or complaint
- Allow specificity for complexity of the diagnosis or complications
- Currently using 10th edition, plans for 11th edition
- Overseen by the World Health Organization in cooperation with the
National Center for Health Statistics in the United States, so allows for international data sharing
The most important things for a DNP to understand is
- Payer Mix of Practice and of NP
- Average Number of Visits
- Most Commonly Used E&M Codes
- Overhead Costs
Payer Mix is
to the proportions of payments received from each kind of payer—federal, state, private, or self-pay. In short, payer mix tells you the types of patients coming to your facility.
Overhead costs
costs represent the cost of doing business. Included in this amount are the salaries of support staff, cost of benefits, facility fees, utilities, and licensing.
Population health
an approach used to improve the
health of a community using nontraditional partnerships among various institutions such as government agencies, educational institutions, healthcare organizations, and so on
Increasing NP scope of practice leads to
more accessible care in underserved areas and reduces costs by reducing emergency room use
- estimated : annual Medicare cost savings of US$44.5 billion nationally
Calculate NP Contribution*** ask kourtney about adding table example from slide 11 and 12
- Examine the Nurse Practice Act in your state. What opportunities exist for APRNs to expand their scope of practice? What can you do to effect legislative change?
