ED Coding and Reimbursement Alert

Although Medicare and other payers may allow payment for specific services provided by nurse practitioners (NPs) and physician assistants (PAs), state legislation and individual hospitals regulate which procedures and services they are licensed to perform. Coders should keep five points in mind when reporting services provided by nonphysician practitioners (NPPs) in the ED: 1. Which services can NPs and PAs provide in the ED? According to Michael Powe, director of reimbursement for the American Academy of Physician Assistants (AAPA), Medicare does not restrict the types of care PAs and NPs can provide but defers to state practice laws. Most NPPs are allowed great latitude in line with their training and level of experience that ranges from performing physical exams to initiating basic and advanced life support, to reduction of fractures, to thoracentesis. State practice laws, the supervising physician or the institution determines the precise services an NPP can provide.

Most often, NPPs report the appropriate-level E/M ED service (99281-99285). They may also perform initial observation care (99218-99220) and observation discharge services (99217). "Medicare puts no limits on the level of service that may be provided, up to and including level-five codes," says Margaret Fitzgerald, MS, APRN, BC, FAANP, president of Fitzgerald Health Education Associates, a firm based in North Andover, Mass., that provides continuing education to nurse practitioners and advance-practice and ambulatory-care nurses.

NPPs also report any specific procedures performed in addition to the E/M services. For example, if an NP placed a peripherally inserted central catheter (PICC) line in a 68-year-old patient, you should also report 36489* (Placement of central venous catheter [subclavian, jugular, or other vein][e.g., for central venous pressure, hyperalimentation, hemodialysis, or chemotherapy]; percutaneous, over age 2). 2. What supervision requirements govern NPPs? Supervision distinctions exist between NPs and PAs. Medicare requires NPs to have physician collaboration, while state law requires PAs to be supervised by a physician. "However," Powe says, "Medicare requirements contain no reference that the supervising physician must be in the hospital when a PA provides emergency services. They allow for electronic communication, which means the physician must be accessible by phone or a similar device. In addition, Medicare rules do not require that a physician sign off on notes PAs write in medical charts." Medicare rules for NPs are similarly nonrestrictive, Fitzgerald adds. Institutional and individual payer policies may establish stricter guidelines stating, perhaps, that a physician must be in the ED while the PA provides care or that a physician must review and sign the chart after the PA has provided the service. "This is rare," Powe notes. "The trend is for private payers to follow state law, as opposed to something more restrictive." 3. Should an NPP's services be reported as [...]