1. Collaborative Care Models Pennsylvania Chapter American College of Cardiology April 28, 2006 Michelle Ashby, CRNP Paul Casale, MD The Heart Group Lancaster, 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 Private Practice University/Hospital University/Hospital “Lease Agreements” “Lease Agreements”

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

5. Hospital AdmissionsAdmissions ConsultsConsults RoundsRounds Nursing callsNursing calls ProceduresProcedures On Call coverageOn 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 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 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? When does the NP/PA need to bill directly? (with NP/PA’s billing number, 85%reimbursement) (with NP/PA’s billing number, 85%reimbursement) New patientsNew patients Established patients with new problemsEstablished patients with new problems Physician is not physically present in the office suitePhysician is not physically present in the office suite www.cms.hhs.gov/MLNMattersArticles/downloads/SE04 41.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. Documentation of Shared Visits

16. 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 providersHealth 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 changesNPI remains with the provider regardless of job or location changes In use by May 23, 2007, but small health plans have until May 23, 2008In 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 specialtyMedicaid 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/BulletinManage Dir/003673169.aspx?BulletinId=1133MA Bulletin (12/16/05) Clarification of Enrollment Policy for CRNPs http://www.dpw.state.pa.us/Business/BulletinManage Dir/003673169.aspx?BulletinId=1133

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

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