Medicare & Medicaid Rules, Billing

Collaborative Agreement: When a PMHNP decides to collaborate with a physician, it is to enhance the quality of patient care and improve outcomes. According to the American Association of Critical-Care Nurses (AACN):

A collaborative practice agreement is a written statement that defines the joint practice of a physician and an APN in a collaborative and complementary working relationship. It provides a mechanism for the legal protection of the APN and sets out the rights and responsibilities of each party involved. All APNs, regardless of practice setting, should be knowledgeable about aspects of a collaborative practice agreement before they sign one. The purposes of this article are to delineate basic guidelines for evaluating and developing a collaborative practice agreement and to identify areas of special concern for APNs.

When working in outpatient clinics, a physician is one of the most important aspects of care and the expectations vary greatly depending on the state and acuity. In general, the parameters of a functional outpatient mental health clinic include:

• Boundaries: the provider establishes a schedule, honor appointments, professionalism, privacy, and respect
• Documentation: progress and process notes
• Length of the session, fees, and informed consent
• Policies for: contact, payment, cancellations, missed appointments, telephone/various means of communication or contact

Financing

Coding & Billing:

• Diagnostic Coding: International Classification of Diseases, 10th edition (ICD-10) used for diagnosis, therapy, surgery consultation…etc.
• Evaluation and Management (E&M) codes: pertains to the level of care
• Current Procedural Terminology (CPT): pertains to the level of care provided, developed by the American Medical Society and used to describe medical treatments and procedures.
• CPT codes are required for billing.
• Universal Billing (UB): describes the hospital services, including demographic information, diagnostic codes, and other charges for services.

Third-party payers: business/schools wanting health services for employees or students, health maintenance organizations (HMO’s), Medicaid, and Medicare. Types of Medicaid and Medicare.

Services that are not covered by Medicare

• Dental exams, most dental care or dentures
• Routine eye exams, eyeglasses, or contacts
• Hearing aids or related exams or services
• Most care while traveling outside the United States
• Help with bathing, dressing, eating, etc. (custodial care)
• Comfort items such as a hospital phone, TV, or private room
• Long-term care
• Cosmetic surgery
• Most chiropractic services
• Acupuncture or other alternative treatments
• Routine foot care

The best way to find out if Medicare covers what you need is to talk to your doctor or other health care provider. Or, visit medicare.gov/coverage and type in your test, item, or service, to get a breakdown of what is and isn’t covered.

Medicare Rules for an NP

• Be a registered nurse who is authorized and licensed by the state to practice as a nurse practitioner by Dec. 31, 2000; or
• Must be certified by a recognized national certifying body that has established standards for NPs (e.g. American Academy of Nurse Practitioners, American Nurses Credentialing Center, AACN Certification Corp., or National Board on Certification of Hospice and Palliative Nurses); and
• Possess a master’s degree in nursing.

–hospitalist

Incident-to-Billing: This includes multiple services in outpatient settings, for example, if a medical student sees a patient, that patient may get billed for also seeing a “physician”. It may not seem fair but technically it’s allowed because the doctor is “supervising” the resident. One of the reasons why this can be an issue is because the patients will see an increase in costs, even though they haven’t physically seen the main physician.

In simpler terms, with a collaborating agreement, the NP and the physician do not have to be in the same room to provide treatment or require direct supervision. Collaboration is not required for all decisions. Incident-to-billing is not allowed in a hospital setting because the NPS should bill under their own services, but there are other ways to bill for inpatient settings. Additional information is found here.