Nurse Practitioners and Physician Assistants: How Expanding Reimbursement and Scopes of Practice Can Facilitate High-Quality, Efficient Healthcare

Regardless of the future of the Patient Protection and Affordable Care Act, the demand for healthcare will continue to increase as the population of the United States ages and increases. One way of meeting this increasing demand is by using licensed and certified health professionals to the fullest extent permitted by law. This article focuses on the optimal deployment of nurse practitioners (NPs) and physician assistants (PAs) in light of changing state laws and new federal programs such as Chronic Care Management (CCM) and Transitional Care Management (TCM).

What is a Nurse Practitioner?

NPs are one of four categories of advanced practice registered nurses (APRNs). The other APRNs are certified registered nurse anesthetists, certified nurse-midwives, and clinical nurse specialists. The American Association of Nurse Practitioners (AANP) defines NPs as follows:

Nurse practitioners (NPs) are licensed, independent practitioners who practice in ambulatory, acute, and long-term care as primary and/or specialty care providers. Nurse practitioners assess, diagnose, treat, and manage acute, episodic, and chronic illnesses. NPs are experts in health promotion and disease prevention. They order, conduct, supervise, and interpret diagnostic and laboratory tests, prescribe pharmacological agents and non-pharmacologic therapies, as well as teach and counsel patients, among other services.(1)

According to the AANP, NPs should not be referred to by other designations. Note the following:

The use of terms such as mid-level provider and physician extender in reference to nurse practitioners (NPs) individually, or to an aggregate inclusive of NPs, is inaccurate and misleading. The American Association of Nurse Practitioners opposes the use of these terms and calls on employers, policymakers, healthcare professionals, and other parties to refer to NPs by their title.(2)

What is a Physician Assistant?

The American Academy of Physician Assistants defines PAs as follows:

A physician assistant (PA) is a nationally certified and state-licensed medical professional. PAs practice medicine on healthcare teams with physicians and other providers. They practice and prescribe medication in all 50 states, the District of Columbia, the majority of the U.S. territories, and the uniformed services. PAs are experts in general medicine. They undergo rigorous medical training. PAs must take a test in general medicine in order to be licensed and certified. They must graduate from an accredited PA program and pass a certification exam. Like physicians and NPs, PAs must complete extensive continuing medical education throughout their careers.(3)

Scopes of Practice for Nurse Practitioners and Physician Assistants

The legally permissible tasks, duties, and responsibilities of a profession are referred to as the profession’s “scope of practice.” Scopes of practice are established by state legislatures and by state boards created by the legislatures.

Nurse Practitioners

Each state has a nurse practice act and a board of nursing. Each board of nursing is empowered by the state’s nurse practice act to promulgate regulations and rules that have the force of law. Boards of nursing also issue policies and make determinations about alleged violations of the nursing law.

The scope of practice for registered nurses, licensed practical (or vocational) nurses, and APRNs in each state is determined by the nurse practice act and the board of nursing. In recent decades there have been intense legislative debates about what clinical tasks and procedures APRNs should be permitted to do, and whether they should be required to perform these under the supervision or oversight of a physician. The AANP has summarized NP law by dividing the states into three categories based on how much NPs are permitted to do in each state:

• Full practice: State practice and licensure law permits all NPs to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including prescribed medications—under the exclusive licensure authority of the state board of nursing. This is the model recommended by the Institute of Medicine and the National Council of State Boards of Nursing.

• Reduced practice: State practice and licensure law reduces the ability of NPs to engage in at least one element of NP practice. State law requires a collaborative agreement with an outside health discipline in order for the NP to provide patient care, or limits the setting or scope of one or more elements of NP practice.

• Restricted practice: State practice and licensure law restricts the ability of an NP to engage in at least one element of NP practice. State requires supervision, delegation, or team management by an outside health discipline in order for the NP to provide patient care.(4)

Currently, 21 states and the District of Columbia fall into the first category, 17 into the second, and 12 into the third.

Physician Assistants

The scope of practice for PAs also is determined by state legislatures. Because PAs are required by law to work under the authority of at least one physician (MD or DO), oversight of PAs is most frequently assigned to the state board of medical examiners.

The degree of required physician oversight and supervision of PAs varies from state to state. As PAs have proven their ability to provide high-quality care, state legislatures have lessened (but not eliminated) the degree of physician oversight under which PAs are required to practice. These legislative changes have contributed to the more expansive deployment of PAs in healthcare delivery settings.

Implications for Medical Practices

Medical practice managers should have some basic familiarity with the state NP and PA laws, and should make appropriate recommendations to their providers about staffing structure and division of responsibilities.

Medicare Reimbursement for Nurse Practitioners and Physician Assistants

NPs and PAs can be reimbursed under Medicare in two ways. The following section presents a simplified overview of these two reimbursement options.

Reimbursement at 100% of the Allowable Physician Rate

NPs and PAs working under direct physician supervision, and providing services incident-to the services of a physician, can be reimbursed at 100% of the reimbursement rate for physicians. The following conditions must be met in order for the services of NPs and PAs to be billed incident-to the services of a physician and reimbursed at the 100% rate:

• The physician must initiate treatment of the patient and make a diagnosis. After the physician’s initial diagnosis, an NP or PA is permitted to provide care to the patient in accordance with the physician’s diagnosis.

• Services of the NP or PA must be provided under direct physician supervision. CMS defines “direct physician supervision” as an overseeing physician being present in the office suite and immediately available, although not necessarily in the same room. (The overseeing physician does not have to be the initiating physician.)(5)

• Services of the NP or PA must be incident-to those of the physician. Services are “incident-to” if they are an “integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness.”(6)

• If these conditions are met, the services of the NP or PA must be billed under the physician’s National Provider Identifier (NPI) number in order to be reimbursed at the 100% rate.

Reimbursement at 85% of the Allowable Physician Rate

If any of the listed conditions are not met, the services of an NP or PA must be billed at 85% of the allowable physician rate. If, for example, during a follow-up visit with an NP or PA, a patient asks for treatment of a condition that was not part of the physician’s initial diagnosis, the services of the NP or PA would not be incident-to those of the physician, and therefore could not be billed as incident-to. Or if an overseeing physician is not on the premises, the services of the NP or PA are not being provided under direct physician supervision, and cannot be billed at 100% of the allowable physician rate. An NP or PA must use her or his NPI number when submitting non-incident-to services for reimbursement, and cannot use the physician’s NPI number.

Implications for Medical Practices

Because of the direct physician supervision requirement for 100% reimbursement of the services of an NP or PA, medical practice managers must coordinate the schedules of physicians, NPs, and PAs to make sure there is an overseeing physician in the office suite and immediately available whenever NPs or PAs are providing Medicare services.

Chronic Care Management and Transitional Care Management

CCM and TCM are two relatively new Medicare programs; CCM went into effect January 1, 2015, and TCM began January 1, 2013. Two distinctive elements of the CCM and TCM programs are: (1) reimbursement is provided for certain non–face-to-face services; and (2) some services can be furnished by clinical staff such as NPs and PAs under the general (as opposed to direct) supervision of physicians and can be reimbursed at 100% of the Medicare rate. Both of these programs provide new opportunities for provision of care by NPs and PAs.

Chronic Care Management

CCM reimburses physicians and other clinical staff (including NPs and PAs) for non–face-to-face services such as care coordination, management of medications, and being available 24 hours a day as a professional resource for patients and clinical personnel caring for the patient. At least 20 minutes each month of CCM services must be provided by clinical staff in order to bill for CCM reimbursement under CPT Code 99490. Only Medicare patients with “two or more chronic conditions expected to last at least twelve months, or until the death of the patient” are eligible to participate in the CCM program.(7)

Transitional Care Management

The purpose of TCM is to provide assistance to Medicare beneficiaries who are being discharged from inpatient hospital settings and are returning to their homes or other community settings, and who have medical issues that require moderate or greater clinical decision-making. Reimbursable TCM services are available for 30 days (starting from the date of discharge from the inpatient setting), and can be provided by physicians and other clinical staff such as NPs and PAs. Under TCM, the healthcare provider must accept responsibility for the patient’s care during the 30-day period, must have at least one face-to-face visit with the patient, and must provide certain non–face-to-face services.(8)

TCM services are billed under CPT Codes 99495 and 99496. During the 30-day TCM period, CCM services (CPT Code 99490) cannot be billed.

Implications for Medical Practices

Medical practice managers in specialties conducive to CCM and TCM should compare costs and benefits of CCM and TCM involvement and offer recommendations to their providers and other decision-makers. A cost–benefit analysis is especially important because, as indicated earlier, billing CPT Code 99490 for CCM services is not permitted during the 30-day TCM period.

References

1. Scope of Practice for Nurse Practitioners. American Association of Nurse Practitioners; www.aanp.org/images/documents/publications/scopeofpractice.pdf . Accessed December 11, 2016.

2. American Association of Nurse Practitioners. Use of terms such as Mid-Level Provider and Physician Extender. www.aanp.org/images/documents/publications/useofterms.pdf . Accessed December 11, 2016.

3. American Academy of PAs. What is a PA? www.aapa.org/what-is-a-pa/ . Accessed December 11, 2016.

4. American Association of Nurse Practitioners. State Practice Environment. www.aanp.org/legislation-regulation/state-legislation/state-practice-environment . Accessed December 11, 2016.

5. Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule, Access to Identifiable Data for the Center for Medicare & Medicaid Innovation Models and Other Revisions to Part B for CV 2015. Fed Regist. 2014;79(219):67547-68092. 42 CFR§403, 405, 410 et al.

6. Centers for Medicare & Medicaid Services. Covered medical and other health services. In: Medicare Benefit Policy Manual. CMS publication 100-02. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf . Accessed December 11, 2016.

7. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Chronic Care Management Services. www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/DownloadsChronicCareManagement.pdf . Accessed December 11, 2016.

8. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Transitional Care Management Services. www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf . Accessed December 11, 2016.