SCCM - Society of Critical Care Medicine

Non-Physician Providers in Critical Care

Walter A. Boyle III, MD, FCCM*
Washington University
School of Medicine
St. Louis, Missouri, USA

Mary Beth Beyatte, ACNP-BC**
Barnes-Jewish Hospital
Washington University
School of Medicine
St. Louis, Missouri, USA

Robert Grabenkort, PA, MMSc, FCCM***
Emory University
Duluth, Georgia, USA

It is predicted that “the severe shortage of physician intensivists is expected to continue into the next decade and beyond.”(1) The exponential rise in the U.S. population’s median age and the rapidly increasing demand for state-ofthe- art critical care services – including intensivist oversight and around-the-clock coverage – all but ensure a significant shortage of physician intensivists in the foreseeable future.(1,2) This 21st century workforce crisis in critical care draws historical comparison to the shortage of primary care physicians in the latter half of the 20th century, a circumstance that provided an important turning point in the training and acceptance of non-physician providers (NPPs) and ultimately led to their expanded roles within medical practice models.

Similarly, many critical care groups today are exploring ways to conserve their existing physician provider workforce and improve patient care by integrating critical care-qualified NPPs into their intensive care unit (ICU) staffing models.(3)

Provider Status and Physician Collaboration/Supervision The elevated status of NPPs – including nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs) – became official with the 1997 passage of the congressional Balanced Budget Act. NPPs are now recognized by the Centers for Medicare and Medicaid Services (CMS) as healthcare providers eligible to obtain individual provider numbers and bill under Medicare Part B for services that might otherwise be billed as physician services. These include evaluation and management (E&M) services and certain procedures that fall within an NPP’s scope of practice.(4,5) To take advantage of this provider billing status, an NPP must meet the specified training and certification requirements. An NPP also must be licensed to practice in his or her individual state, enter into a physician supervision or collaborative practice arrangement, and adhere to scope of practice regulations as defined by state nursing and/or medical boards. In general, CMS usually defers to state legislation, which may vary in breadth and detail and should be researched on an individual basis. The nuanced parameters and state-by-state variance of these rules have led to the now-standard practice of defining physician/NPP collaborative or supervisory arrangements with legal documentation that is developed by counsel to ensure regulatory compliance. Often drafted as a supplement or addendum to the formal agreement, practice parameters delineate such matters as specific scope of practice and requirements for consultation and referral. They should be defined in sufficient detail to serve as a job description for the NPP, as well as a policies and procedures manual for the collaborative or supervisory practice.(6)

Background and Training
Incorporating NPPs into a critical care practice model requires consideration of the specific background and training of each NPP. The acute care nurse practitioner (ACNP) specialty has seen much growth and development in recent years, as interest has increased for specific programs directed at educating and training NPs to manage patients with acute and critical illnesses.(3,7) Similarly, several PA postgraduate programs in critical care now exist.(3) Regardless of an NPP’s background, training in certain critical care procedures may be lacking or limited, as will training in the specific service and documentation requirements for billing hospital visits, critical care services, and other compliance-related
matters.(7) Thus, an extended NPP orientation – generally at least three to six months – should be expected and encouraged, particularly for recent graduates. Full privileges are granted after an NPP has demonstrated full competence in the skills required to undertake the critical care provider duties.

Employment Relationships
Hospitals or provider groups may employ NPPs directly or contract with them in the same way they do with other critical care providers. However, in order for NPPs, their hospitals, or their provider groups to bill CMS for the services provided to Medicare beneficiaries, the NPPs’ salaries and other associated expenses must not be included on the hospital cost report submitted for hospital reimbursement under Medicare Part A. Given the additional collaboration or supervision requirements, employment relationships in which NPPs are employed directly or aligned with the physician provider group are generally the most straightforward. Such relationships not only eliminate any questions about dual reimbursement under Medicare parts A and B, but also facilitate standardization of supervision or collaborative practice procedures. They also offer cultural advantages, providing consistent channels of authority and responsibility. Such considerations are essential in creating and maintaining effective, professionally rewarding provider staffing models that incorporate NPPs.

Billing and Coding Issues
Some nuances in CMS billing and coding related to NPP services have generated confusion and are important to understand. First, “incident to” billing (a CMS coding method that allows services performed by an NPP to be billed under a supervising or collaborating physician’s provider number in order to receive 100% reimbursement from Medicare, rather than the 85% reimbursement rate paid for NPP provider services) is only permitted for outpatient services. “Incident to” billing does not apply to any inpatient services performed in an ICU setting. “Split services,” a billing practice that allows physicians and NPPs to combine their services and bill together under the physician’s provider number at full reimbursement, is permitted in the inpatient critical care setting. However, this method does not apply to specific critical care service Current Procedural Terminology® (CPT) codes (i.e., 99291 and 99292). Also, additional requirements for the physician to have face-to-face contact with the patient and to document his or her portion of the split service separately (e.g., hospital subsequent visit codes 99231 to 99233) often are unnecessary and more timeconsuming than the small additional amount of compensation justifies. If an NPP and a collaborating or supervising physician both provide time-based critical care services on the same day, both providers’ time may be added together, just as it would with other providers from the same group. This type of shared service must be billed under the NPP’s number at the lower rate of reimbursement.

The coding issues discussed here are specific to Medicare. Other payors – including Medicaid – may have their own coding methods, reimbusement rates, and provider identification numbers, as well as differing rules regarding NPP provider status and scope of practice, and must be consulted as applicable.

Financial Productivity
Regardless of the specific employment model, NPP billing revenues often are insufficient to cover the NPP salaries and other costs; financial productivity among NPPs may become an issue. A survey of NPP (ACNP) activities within Barnes-Jewish Hospital in Missouri found this issue is related largely to the substantial amount of NPP time (approximately 50% in the study) spent on non-reimbursable activities (see Figure 1). These activities included providing administrative services (e.g., coordination of care), attending to holistic aspects of care, and facilitating communication with nurses, other providers, and patient families. In addition, ACNP providers spent a significant amount of time on important, but non-billable, nursing activities. NPPs also devoted extra time to patient care while billing at the reduced reimbursement rate for services not based on time. Given that these “nonproductive” activities provide several benefits, such as increased patient satisfaction and decreased hospital costs,(3) hospitals should support these additional efforts.

Unless the inclusion of NPP expenses on the hospital cost report generates sufficient revenue under Medicare Part A to justify foregoing direct provider billing under Medicare Part B (a very unlikely scenario), a hospital and provider group “shared expense model” may be the most efficient and cost-effective approach to achieving the shared mission of delivering quality care to intensive care patients and their families. In this model, the NPPs are integrated into the provider group of collaborating and/or supervising physicians (which bills and collects for all billable provider services), while the hospital contributes revenue to the group for the non-billable hospital services provided by the NPPs, including the important nursing and hospital-support activities described.

References:

1. Health Resources and Services Administration. The critical care workforce: a study of the supply and demand for critical care physicians. Report to Congress. http://bhpr.hrsa.gov/healthworkforce/reports/criticalcare/default.htm. Published in 2006. Accessed on July 21, 2009.

2. Angus DC, et al. Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: Can we meet the requirements of an aging population? JAMA. 2000;284:2762–2770.

3. Committee on the Future Health Care Workforce for Older Americans, Institute of Medicine. Retooling for an Aging America: Building the Health Care Workforce. 1st edition. National Academies Press; 2008.

4. Kleinpell RM, et al. Nurse practitioners and physician assistants in the intensive care unit: An evidence-based review. Crit Care Med. 2008;36:2888–2897.

5. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. Chapter 12 - Physicians/Nonphysician Practitioners. http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf. Published April 24, 2009. Accessed July 21, 2009.

6. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual. Chapter 15 – Covered Medical and Other Health Services. http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Published April 24, 2009. Accessed July 21, 2009.

7. Kleinpell RM, et al. Skills Taught in Acute Care NP Programs: A National Survey. Nurse Pract. 2006;31:11-13.

8. Kleinpell RM, et al. Developing an Advanced Practice Nursing Credentialing Model for Acute Care Facilities. Nurs Adm Q. 2008;32:279–287.

Disclosures:

*Author has no disclosures to report

**Author has no disclosures to report

***Author has no disclosures to report