The NP's Role in Nursing Facilities
Medicare requires that the initial visit (history and physical), for the purpose of certifying that the patient requires skilled care, must be performed by a physician. An NP may, however, make a "medically necessary" visit without an initial physician visit; this could occur when a newly admitted Medicare patient in a skilled nursing facility develops a problem that requires medical evaluation and intervention, before being seen by the physician. Girvin-Reisser advised cautious use of this practice because it could be viewed as an unnecessary visit (ie, if the physician were available to see the patient at the time of admission, only one visit would have been needed). All subsequent visits may be performed by an NP (or other nonphysician), alternating with the physician.
NPs may perform the initial history and physical for new long-term care (nonskilled) admissions. NPs may also make additional visits, which must be substantiated based on the patient's need (ie, acute illness). Medicare provisions permit 1.5 visits per month; more than this frequency may invite increased scrutiny in the form of an audit. Medical necessity must be documented!
Assuming state law permits, Medicare allows NPs to help with monitoring and managing patient conditions, counseling patients and families, performing certain procedures, annual physical examinations, communication with hospital and community physicians, and discharge visits.
Medicare operates 2 programs. Part B, which covers physician services, is the focus of this paper. Part A covers hospitalization, skilled nursing facilities, and some home services. Generally, Medicare requires that services are billed under the provider number of the individual performing the service. However, certain services and supplies are covered "incident to" a physician's professional services. This may include NP services if they are:
An integral part of the physician's professional service
Rendered without charge or included in the physician's bill
Furnished in the physician's office/clinic
Furnished under physician direct personal supervision, meaning the physician is present in the same office suite and immediately available
NP services that are billed "incident to" a physician's service may be reimbursed at 100% of the physician's fee schedule. However, there is no "incident-to" billing in the nursing facility because it does not meet the above criteria. NPs providing services in a nursing facility must bill Part B under their own provider number. Medicare reimburses NPs at a rate of 85% of the physician fee schedule. The NP must have a collaborative relationship with the physician and must not be an employee of the nursing facility.
Other Billing Issues
During a "Part A" stay in a skilled nursing facility, certain procedures that may be performed by an NP may not be reimbursed by Part B, because they are "bundled" in the facility's daily rate. Girvin-Reisser used application of an Unna boot (a specialized gauze wound dressing) as an example. The NP can be reimbursed for such procedures only by having a contractual agreement with the facility to be paid directly.
Third-party payers other than Medicare may have different policies regarding NP services. Some may not recognize NPs as covered providers. It is best to obtain, in writing, the third party payer's policies regarding coverage of NP services before submitting a claim.