A common question that nurse practitioners ask is “How often can a patient be seen in a nursing home by an APRN?” The answer is related to the medical necessity of the actual visit, not whether the nurse asked you to see the patient.
Therefore you can see the patients in the nursing home as often as medically necessary. This means that you can see the patient often or not at all. If they aren’t sick or having a medical problem then do not see them.
Evaluation and management (E/M) services is when you see a patient then bill insurance for the visit. Medicare allows APRNs to evaluate and treat patients in the nursing home setting. This doesn’t mean you are able to see the patients for everything that comes across your desk.
APRNs and PAs may perform medically necessary visits prior to or before and after the doctor’s initial comprehensive visit. There will be multiple opportunities to evaluate patients.
Throughout your day, you will need to determine if you can evaluate the patient or should you just write the order and move on. There will be many tasks that could be delegated to nursing and others that require an evaluation.
CMS (medicare) released a memorandum that clarifies the physician delegation of tasks in SNFs and NFs. This document helps to clarify what tasks can be completed by a nurse practitioner.
CMS refers to “non-physician practitioners such as nurse practitioners, physician assistants, or clinical nurse specialists as “NPPs” formerly referred to as “physician extenders.”
Some variables go into determining if a patient can be elevated for an E&M visit. For instance, the doctor is required to see the patients on admission to the facility then every thirty days for the first 90 days. After the third month, the nurse practitioner can alternate federal regulatory visits with the physician.
When thinking if a visit is needed, determine if your visit will record residents’ medical progress, and will it help maintain/improve their mental/physical status?
Medically necessary services
These types of visits are determined by the patient’s medical condition, not regulatory requirements. CMS defines medical necessity as “services reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
According to CMS, these visits must include the following.
- Reason for the service
- Services provided to the patient
- Who performed the service.
Unfortunately, Medicare isn’t very clear-cut when it comes to visiting frequency. After reviewing medical groups and feeds, we found some groups seeing patients as often as 1-2 times a week for skilled and once a month for long-term depending on their condition.
When you work in the nursing home setting, you see “long-term/chronic” patients. You will find that the elderly have many acute problems that are not reported to medical providers. The patient will sometimes tell a nurse’s aide, housekeeper, or family member what is wrong instead of a nurse.
If they report to you as a medical provider, you can evaluate the patient. However, you should include the unit nurse in the care of the patient after you have seen them. This way the nurse will know the condition of their residents.
Types of Nursing home visits
1) Emergency and STAT visits: These are usually unplanned evaluations that come up during the shift. You may be seeing other patients when the facility calls a “code” or has a patient with a rapid change in condition. We will discuss the various types of nursing homes in more detail in another blog post.
2) An acute change of condition visit: These types of evaluations pop up during the day or the previous night. These types of visits are usually more recent changes in condition. The nurses request a visit or the POA/families ask that patient to be evaluated by a medical provider.
3) Follow-up visits: When doing these types of visits, its usually following an illness such as pneumonia, CHF, or other events that require a medical provider to document stability and whether the patient requires further interventions.
4) Regulatory or “Monthlies”: These federally mandated visits are required to keep the nursing home in compliance with state and federal inspections. There are many rules regarding these types of visits which we will write about in a future blog post.
5) New admission evaluations to facility: when a patient arrives at the nursing home, they will need to been seen for review of their W10 and discharge summary. The patient will also need a medical evaluation to determine if the proper treatment is in place. Never assume that just because they come from the hospital that everything is good.
6) Transfer to the hospital or to avoid hospitalization: sometimes patient’s health status decompensates. When their health is declining, you will need to provide medical care and management. By elevating and treating them early, you may avoid unnecessary and avoidable hospitalization.
There will also be times when you evaluate them and realize the level of care you can provide will require hospitalization. There are tips for avoiding hospitalization that will be discussed in another blog.
7) Discharge home: DC visits are usually done 48 hours or less prior to the patient going home. There are many things you will need to do to prepare for the discharge of a patient from the nursing home.
8) Death of patient with the pronouncement by the provider: An evaluation and management visit can be completed for a patient that has died when the medical provider is the one who pronounces the patient. If you a just signing the death certificate but you didn’t actually pronounce the patient, you would not be able to bill for this visit.
However, if you did pronounce the patient, you would bill for a 99315 or 99316 discharge visit based on the time it took you for a visit.
Over time you will become familiar with your patients. You will know what to address and when to follow up with them. When you first start, you will not know the residents, so there will be less wiggle room in determining medical necessity for the visit.
Using the types of visits will help you determine how often they can be evaluated for medical visits. Do they fall into one of the categories above? If not, then ask yourself is the visit truly medically needed?
There are vague CMS regulations regarding visits in the nursing home and some state regulations that are beyond the scope of this article. These federal and state regulations vary from state to state. Follow up with your local state board and maybe we will do a blog in the future discussing this topic.
Can a nursing practitioner see new patients in nursing homes?
Care must be taken when seeing a new admit to the facility. New patient evaluations using CPT codes 99304, 99305, and 99306 is completed by the attending medical doctor in skilled nursing facilities. Some regular nursing homes without skilled nursing allow non-physician providers to complete these visits.
Many times, the APRN is the one in the facility when the new patient arrives. In this case, they evaluate the patient, review the W10 and discharge summary from the hospital and approve the orders.
If the medical doctor is coming to the home on the same day, it is best to leave the first visit to the doctor. Some states have requirements that the doctor evaluates the patient within 48 hours of arrival. The facilities will need the MD visit to keep them in compliance.
Most times there is a medical necessity for the APRN or PA to see the patient when they arrive. The doctors usually don’t see the patient on the same day as arrival. This means if there are medical errors on the w10 or discharge summary, it may be prevented by an evaluation.
Plus, nursing homes require the medications to be approved by a medical provider such as a doctor, APRN or Physician assistant. Just make sure to document the medical reason for seeing the patient upon arrival at the facility.
Denial of payment by medicare
Medicare will audit visits that are done by medical providers. If they do not meet the criteria for medicare for medical necessity, you will receive a denial of payment or reversal of payment once an audit is complete.
Plus, if any of your notes are denied payment after an audit, you run the risk of medicare no longer allowing you to bill for services.
Your documentation must support the frequency or medical necessity of the visits, or you will be denied payment for your E&M visit. Just because a facility asks you to see a patient weekly doesn’t mean there is a medical necessity for the visit.
Certifications and re-certifications
Nurse practitioners and physician assistants are allowed to review and sign nursing home patient certifications and re-certifications. Affordable Care Act (ACA) provision gave PA’s ability to sign the certification forms.
Certification and re-certs are required to verify that a resident requires daily skilled nursing care or rehabilitation services. These forms are usually completed by the MDS nurse in the facility and do not usually require a medical visit to complete. However, some providers time them with their initial assessment of the resident so they can determine the validity of what they are signing.
Keep in mind that only those non-physician providers that are not employed by the nursing home are allowed to sign the certification forms.
Show caution when using these forms as a reason for seeing the patient because medicare may deny payment on an audit.
Non-physician practitioner (NPP) employed by nursing homes
Whether or not an APRN works for the nursing home or is independent of the facility also plays a role in whether they can see the patient.
There are more rules about whether or not an employed NPP can elevate patients which we will not get into in this article.
Non-skilled Nursing homes
If your state allows it, non-physician practitioners may provide initial nursing facility visits and other required visits under 42 C.F.R. §§483.40(c)(3). This does not pertain to skilled nursing facilities where the visit requires a physician to complete.
Questionable Practices
Some SNFist companies pressure the boss for MD/NP/PA to generate as many visits as possible. When this happens, experienced providers can become very “creative.”
There are cases when the nurse identifies an issue and the provider doesn’t address everything in one visit. Even if they are able they will still only treat one issue at a time. They treat first what can’t wait till tomorrow then delay care on the other issues. The provider then spaces out visits, resulting in the “medical necessity” going on and on….until medicare catches wind and you get in trouble for overbilling and possible fraud.
Don’t play games with medicare. They have ways of catching fraud, and if you are not careful, you will get in trouble and possibly lose billing rights.
How often can the doctor see the patient?
The residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter.
A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.
There are also state requirements that may mandate patients to be evaluated earlier than ten days. Check with your state board for further requirements.
Is there a maximum amount of patients that can be seen in a day at a nursing home?
There doesn’t appear to be a set limit when it comes to the total number of visits in a day. From what I found, it varies based on how many hours a week you work as a medical provider. Other factors include what kind of patients you’re evaluating and the level of complexity of the resident.
If you have more support from support staff, you will be able to evaluate more patients in a day.
That being said, if you are way above the bell curve for your region, you will set yourself up for an audit with the insurance companies. That doesn’t mean you cannot evaluate and treat a larger amount of patients each day. Many nurse practitioners average between 18 and 22 patients per day, but there are medical doctors that see upwards of 30 to 35 patients a day.
Make sure your documentation is up to par, and you maintain your integrity when deciding who should be evaluated, you should be fine.
Conclusion
There is really no hard and fast rule when it comes to how often patients can be evaluated in the nursing home. The most important thing is to us medical needs and your integrity when deciding whether to evaluate the patient.
Use common sense when deciding whether to see the patient or not. Is there a valid reason? Is there a potential for harm to the resident if you do not provide care? Can this easily have been taken care of with a simple call?
Don’t set yourself up for an audit with the insurance companies. It isn’t worth risking losing the ability to bill insurance for your visits because you over evaluated patients without medical necessity.
References
Center for Clinical Standards and Quality/Survey & Certification Group, March 8, 2013, Department of Health & Human Services Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-15-.pdf
Department of Health & Human Services, Centers for Medicare & Medicaid Services. Evaluation and Management Services. August 2017 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf
