A common question that nurse practitioners ask is \u201cHow often can a patient be seen in a nursing home by an APRN?\u201d The answer is related to the medical necessity of the actual visit, not whether the nurse asked you to see the patient.<\/strong><\/p>\n\n\n\n
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.<\/strong><\/p>\n\n\n\n
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. <\/p>\n\n\n\n
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. <\/p>\n\n\n\n
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. <\/p>\n\n\n\n\n
These types of visits are determined by the patient’s\nmedical condition, not regulatory requirements. CMS defines medical necessity\nas “services reasonable and necessary for the diagnosis or treatment of\nillness or injury or to improve the functioning of a malformed body\nmember.” <\/p>\n\n\n\n
According to CMS, these visits must include the\nfollowing. <\/p>\n\n\n\n
Unfortunately, Medicare isn\u2019t 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.<\/p>\n\n\n\n
When you work in the nursing home setting, you see \u201clong-term\/chronic\u201d\u00a0 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\u2019s aide, housekeeper, or family member what is wrong instead of a nurse. <\/p>\n\n\n\n
If they report to you as a medical provider, you can evaluate\nthe patient. However, you should include the unit nurse in the care of the\npatient after you have seen them. This way the nurse will know the condition of\ntheir residents. <\/p>\n\n\n\n
1) Emergency and STAT visits<\/strong>: These are usually\nunplanned evaluations that come up during the shift. You may be seeing other\npatients when the facility calls a \u201ccode\u201d or has a patient with a rapid change\nin condition. We will discuss the various types of nursing homes in more detail\nin another blog post.<\/p>\n\n\n\n
2) An acute change of condition visit<\/strong>: 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.<\/p>\n\n\n\n
3) Follow-up visits<\/strong>: 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. <\/p>\n\n\n\n
4) Regulatory or \u201cMonthlies\u201d<\/strong>: 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. <\/p>\n\n\n\n
5) New admission evaluations to facility<\/strong>: when\na patient arrives at the nursing home, they will need to been seen for review\nof their W10 and discharge summary. The patient will also need a medical\nevaluation to determine if the proper treatment is in place. Never assume that\njust because they come from the hospital that everything is good. <\/p>\n\n\n\n
6) Transfer to the hospital or to avoid hospitalization:\n<\/strong>sometimes patient’s health status decompensates. When their health is declining,\nyou will need to provide medical care and management. By elevating and treating\nthem early, you may avoid unnecessary and avoidable hospitalization. <\/p>\n\n\n\n
There will also be times when you evaluate them and\nrealize the level of care you can provide will require hospitalization. There\nare tips for avoiding hospitalization that will be discussed in another blog. <\/p>\n\n\n\n
7) Discharge home<\/strong>: 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. <\/p>\n\n\n\n\n
8) Death of patient with the pronouncement by the provider:<\/strong> 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\u2019t actually pronounce the patient, you would not be able to bill for this visit.<\/p>\n\n\n\n
However, if you did pronounce the patient, you would bill\nfor a 99315 or 99316 discharge visit based on the time it took you for a visit.\n<\/p>\n\n\n\n
Over time you will become familiar with your patients.\nYou will know what to address and when to follow up with them. When you first\nstart, you will not know the residents, so there will be less wiggle room in\ndetermining medical necessity for the visit. <\/p>\n\n\n\n
Using the types of visits will help you determine how\noften they can be evaluated for medical visits. Do they fall into one of the\ncategories above? If not, then ask yourself is the visit truly medically\nneeded?<\/p>\n\n\n\n
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<\/a> 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. <\/p>\n\n\n\n
Care must be taken when seeing a new admit to the facility.\nNew patient evaluations using CPT codes 99304, 99305, and 99306 is completed by\nthe attending medical doctor in skilled nursing facilities. Some regular\nnursing homes without skilled nursing allow non-physician providers to complete\nthese visits. <\/p>\n\n\n\n
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. <\/p>\n\n\n\n
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. <\/p>\n\n\n\n
Most times there is a medical necessity for the APRN or PA to see the patient when they arrive. The doctors usually don\u2019t 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.<\/p>\n\n\n\n
Plus, nursing homes require the medications to be approved\nby a medical provider such as a doctor, APRN or Physician assistant. Just make\nsure to document the medical reason for seeing the patient upon arrival at the\nfacility.<\/p>\n\n\n\n
Medicare will audit visits that are done by medical\nproviders. If they do not meet the criteria for medicare for medical necessity,\nyou will receive a denial of payment or reversal of payment once an audit is\ncomplete. <\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Your documentation must support the frequency or\nmedical necessity of the visits, or you will be denied payment for your E&M\nvisit. Just because a facility asks you to see a patient weekly doesn\u2019t mean\nthere is a medical necessity for the visit. <\/p>\n\n\n\n
Nurse practitioners and physician assistants are allowed to review and sign nursing home patient certifications and re-certifications. Affordable Care Act (ACA)<\/a> provision gave PA\u2019s ability to sign the certification forms. <\/p>\n\n\n\n
Whether or not an APRN works for the nursing home or\nis independent of the facility also plays a role in whether they can see the\npatient. <\/p>\n\n\n\n
There are more rules about whether or not an employed NPP\ncan elevate patients which we will not get into in this article.<\/p>\n\n\n\n
If your state allows it, non-physician practitioners may provide initial nursing facility visits and other required visits under 42 C.F.R. \u00a7\u00a7483.40(c)(3)<\/a>. This does not pertain to skilled nursing facilities where the visit requires a physician to complete. <\/p>\n\n\n\n
Some SNFist companies pressure the boss for MD\/NP\/PA\nto generate as many visits as possible. When this happens, experienced providers\ncan become very \u201ccreative.\u201d <\/p>\n\n\n\n
There are cases when the nurse identifies an issue and the provider doesn\u2019t 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\u2019t wait till tomorrow then delay care on the other issues. \u00a0The provider then spaces out visits, resulting in the \u201cmedical necessity\u201d going on and on….until medicare catches wind and you get in trouble for overbilling and possible fraud. <\/p>\n\n\n\n
Don\u2019t play games with medicare. They have ways of\ncatching fraud, and if you are not careful, you will get in trouble and\npossibly lose billing rights. <\/p>\n\n\n\n
The residents must be seen by a physician at least\nonce every 30 days for the first 90 days after admission, and at least once\nevery 60 thereafter.<\/p>\n\n\n\n
A physician visit is considered timely if it occurs\nnot later than 10 days after the date the visit was required.<\/p>\n\n\n\n
There are also state requirements that may mandate patients to be evaluated earlier than ten days. Check with your state board for further requirements.<\/p>\n\n\n\n
There doesn\u2019t appear to be a set limit when it comes\nto the total number of visits in a day. From what I found, it varies based on\nhow many hours a week you work as a medical provider. Other factors include\nwhat kind of patients you\u2019re evaluating and the level of complexity of the\nresident. <\/p>\n\n\n\n
If you have more support from support staff, you will\nbe able to evaluate more patients in a day. <\/p>\n\n\n\n
That being said, if you are way above the bell curve\nfor your region, you will set yourself up for an audit with the insurance\ncompanies. That doesn\u2019t mean you cannot evaluate and treat a larger amount of\npatients each day. Many nurse practitioners average between 18 and 22 patients\nper day, but there are medical doctors that see upwards of 30 to 35 patients a\nday. <\/p>\n\n\n\n
Make sure your documentation is up to par, and you maintain\nyour integrity when deciding who should be evaluated, you should be fine.<\/p>\n\n\n\n
There is really no hard and fast rule when it comes to\nhow often patients can be evaluated in the nursing home. The most important\nthing is to us medical needs and your integrity when deciding whether to\nevaluate the patient.<\/p>\n\n\n\n
Use common sense when deciding whether to see the\npatient or not. Is there a valid reason? Is there a potential for harm to the resident\nif you do not provide care? Can this easily have been taken care of with a\nsimple call?<\/p>\n\n\n\n
Don\u2019t set yourself up for an audit with the insurance\ncompanies. It isn\u2019t worth risking losing the ability to bill insurance for your\nvisits because you over evaluated patients without medical necessity.<\/p>\n\n\n\n\n
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<\/a><\/p>\n\n\n\n
Department of Health & Human Services, Centers for Medicare & Medicaid Services. <\/a>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<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"
