Professional Roles and Reimbursement

Nurse Practitioner History and Regulation

  • Loretta C. Ford, PhD, RN, FAAN, and Henry K. Silver, MD, started the first NP program at the University of Colorado in 1965. Initially it was a certificate program and later became a master’s program in the 1970s.
  • The first NPs were pediatric NPs who practised in economically disadvantaged rural areas where there were no physicians due to a severe shortage of primary care physicians.

Regulation of Nurse Practitioners

  • Educational Requirements: An NP must meet the minimal educational requirements mandated by the nurse practice act of the state where they plan to practice.
  • State Nursing Practice Act: Enacted into law by the state legislature; NP’s legal right to practice is derived from the state legislature. Each state has its own nursing practice act containing regulations that dictate educational requirements, responsibilities, and scope of practice for NPs and other nurses (e.g., RNs, LPNs, midwives) who practice in the state. NP practice is not regulated by the federal government, the AMA, or the U.S. Department of Health and Human Services (DHHS).
  • State Board of Nursing (SBON): Responsible for enforcing the state’s nursing practice act; a formal governmental agency with statutory authority to regulate nursing practice. The SBON licenses, monitors, and disciplines nurses and can revoke a nurse’s license after formal hearings.
  • Title Protection: Professional designations such as RN, NP, or APRN are protected by law; it is illegal to use these titles without a valid license. Title protection is mandated by the state’s nurse practice act to protect the public from unlicensed “nurses.”
  • Licensure and Certification:
    • Licensure is a legal requirement to practice as an NP and is obtained through the SBON; NP must meet minimal educational and clinical requirements.
    • Certification is generally a “voluntary” process through a nongovernmental entity (professional nursing associations or specialty organizations).
    • The majority of states now mandate board certification (or certification) as a condition to obtain licensure.
  • Standards of Professional Nursing Practice:
    • Standards are authoritative statements of duties that all RNs, regardless of role, population, or specialty, are expected to perform.
    • The American Nurses Association (ANA) provides Standards of Practice and Standards of Professional Performance.
    • Standards for NPs are published by the American Association of Nurse Practitioners (AANP). Specialty organizations (e.g., Orthopedic Nurses Certification Board) also develop standards.

Collaborative Practice and Practice Environment

  • Collaborative Practice Agreements: A written agreement between a physician and an NP outlining the NP’s role and responsibilities in the clinical practice. A copy must be kept at the NP’s practice setting; most states require an annual review with signatures and dates.
  • State Practice Environment: Varies by state: some states allow full practice under SBON authority, some allow reduced practice, and some have restricted practice where the NP must be supervised or delegated by an outside health discipline (e.g., board of medicine).
  • Agreements With Physicians and Dentists: NPs can sign collaborative practice agreements with physicians (MDs), osteopaths (DOs), and dentists (DMDs/DDSs). Chiropractors (DCs) and naturopaths (NDs) are not typically considered for collaborative practice. In many states, physicians are the only practitioners who can legally sign a death certificate.
  • Prescription Privileges: All 50 states grant prescriptive authority to NPs, including the right to prescribe controlled substances (varies by state).
  • Prescription Pads and Documentation:
    • NP prescription pads/e-prescriptions should include: NP’s name, designation, and license number; practice setting name, address, and phone number; if multiple locations, list other clinics where the NP practices.
    • To reduce fraud, it is best if the DEA number is not listed (only for controlled substances).
    • Tamper-resistant prescription pads are required by Medicare and Medicaid for FDA–controlled substances prescriptions.
    • A controlled substance prescription can be typed but must be signed by the prescribing practitioner on the day it is issued.
  • Schedule II Drug Prescriptions:
    • High potential for abuse with severe psychological or physical dependence.
    • These cannot be called in; must be written on tamper-resistant pads and signed by the prescriber (not stamped).
    • There is variation among state laws regarding Schedule II prescriptions.
    • Examples include: codeine, morphine, hydrocodone, oxycodone, opium, fentanyl, methadone, amphetamines.
  • E-Prescribing (Electronic Prescriptions): A method of sending prescriptions electronically directly to the pharmacy; the preferred method of prescribing by Medicare and Medicaid.
  • Tip: Be able to define standards of practice. NPs receive their “right to practice” from the state legislature.

Leadership Styles and Practice Principles

  • Situational Leadership: Leader adapts style to changing needs; builds rapport; engages staff; theory developed by Blanchard and Hersey.
  • Transformational Leadership: Vision communication, potential charisma, good communication; staff often report higher job satisfaction.
  • Laissez-Faire Leadership: Minimal supervision; hands-off; effective with experienced, autonomous, self-directed staff; may cause anxiety for new staff.
  • Authoritarian (Autocratic) Leadership: Control and structure, many rules; decisions made with little staff input; may demotivate otherwise capable staff.
  • Democratic Leadership: Shared decision-making; more meetings; values relationships and staff input; slower decisions but often better buy-in.
  • Servant Leadership: Leader works alongside others, shares power, grows and develops staff; builds strong relationships; may avoid controversial decisions.

Evidence-Based Practice and Clinical Guidelines

  • Evidence-Based Practice (EBP): Integration of solid clinical evidence into patient care; critically evaluating research for validity, magnitude of effect, and applicability; see Chapter 30, “Evidence-Based Medicine and Epidemiology.”
  • Treatment Guidelines: Contents based on systematic reviews of available clinical evidence; written by national expert panels and/or specialty organizations.
  • Case Management: Case managers (usually experienced RNs) coordinate outpatient management for chronic diagnoses; primarily via telephone; often for diseases like asthma in children, COPD, chronic heart failure, diabetes.
  • Quality Improvement Programs: Monitor and identify problems, measure outcomes, and establish new parameters to improve performance; goals include better patient outcomes, fewer complications, reduced hospitalizations, lower mortality, fewer system errors, and higher patient satisfaction.
  • Patient Outcomes as Quality Indicators: Example outcome measures include disease-specific targets (e.g., for diabetes: ext{A1C} < 6.5\%); poor outcome example: ext{A1C} > 8\%.
  • Risk Management in Healthcare: Systematic process to identify risky practices to minimize adverse patient outcomes and liability; common high-risk areas include medication errors, hospital-acquired infections, patient identification problems, and falls.
  • Accreditation: Voluntary process by nongovernmental associations; evaluates and certifies that an organization meets established standards (e.g., hospital, clinic, nursing program).
  • The Joint Commission (TJC): Independent, not-for-profit organization accrediting healthcare organizations via inspection and evaluation; certification signifies meeting strict requirements; aims to enhance quality of care and patient safety.
  • Sentinel Event Reporting (SE): A sentinel event is a patient safety event that results in death, permanent harm, or severe temporary harm requiring life-sustainment intervention; organizations are expected to conduct RCA and implement improvements; reporting to TJC is strongly encouraged but not always mandatory.
  • Examples of Sentinel Events:
    • Suicide of a patient in a staffed around-the-clock facility or within 72 hours of discharge
    • Unanticipated death of an infant or infant discharged to the wrong family
    • Rape or assault of a staff member, visitor, or vendor
    • Invasive procedure on the wrong patient, wrong procedure, or wrong limb
    • Unintended retention of a foreign object
    • Fire, flame, or unanticipated smoke/heat during patient care
  • Root Cause Analysis (RCA): A structured team process used to identify contributing factors leading to an error; mandated by TJC for SEs; analyzes data to identify root causes (often human, environmental, and system factors); goal is system-level fixes rather than blaming individuals; require at least one corrective action for each root cause.
  • Outcomes Analysis: Tracking patient outcomes using outcome measures (e.g., surveys, questionnaires).

Theoretical Concepts for Health Behavior and Systems

  • Health Belief Model (HBM): Explains/predicts health behaviors based on perceived threat and perceived benefits/barriers; constructs include perceived susceptibility, perceived seriousness, perceived benefits, perceived barriers, and self-efficacy; modifying factors include demographics and social factors. Example: comparing a 50-year-old smoker with a recent MI to a 16-year-old with obesity; the former is more likely to change due to seriousness and age.
  • Family Systems Theory (Murray Bowen): All parts of a system are interrelated; dysfunction in one member affects the entire family; family members compensate or absorb stress; example: a parent with alcoholism may cause the oldest child to assume parent-like duties, potentially leading to distress in that child.
  • Transtheoretical Model (Stages of Change): Five stages of intentional behavioral change (Prochaska & DiClemente):
    • Precontemplation (not ready, denial of adverse effects)
    • Contemplation (acknowledges problem; weighs pros/cons)
    • Preparation (plans action; sets quit date; obtains nicotine replacement)
    • Action (takes steps to change)
    • Maintenance (sustains change; avoids relapse)
  • Tip: Recognize Murray Bowen’s family systems theory; learn to identify a stage in the stages of change model.

Patient-Centered Medical Home (PCMH)

  • PCMH is a healthcare delivery model focused on patient-centered primary care; the patient and family are integral members of the healthcare team.
  • Care is delivered primarily in the home setting, with a team that may include physicians, APRNs, PAs, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators.
  • Care is coordinated to ensure smooth transitions between home, hospital, home health, and community services.
  • The patient and/or family has 24/7 access to a team member by phone, video chat, or email.

Human Genetic Symbols

  • The exam may include questions about genetic symbols (Table 28.1 Genetic Symbols):
    • Healthy male: empty square; diseased/affected male: filled square
    • Healthy female: empty circle; diseased/affected female: filled circle
    • Deceased: diagonal dash across symbol

Reimbursement, Billing, and Coding Essentials

  • Budget Reconciliation Act of 1989 (HR 3299): First law allowing NPs to be reimbursed directly by Medicare; previously, only certified pediatric and family NPs in designated rural areas could be primary providers.
  • Balanced Budget Act of 1997: Along with the Primary Care Health Practitioner Incentive Act, broadened Medicare coverage of NP and CNS services.
  • HIPAA (1996): Required health providers to have a National Provider Identifier (NPI) to bill Medicare and Medicaid; NPs can be reimbursed directly by Medicare Part B, Medicaid, Tricare, and some private plans. Medicare reimbursement rate for NPs is 85\% of the Medicare Physician Fee Schedule.
  • "Incident To" Billing and Medicare: A mechanism to bill Medicare for outpatient services by a nonphysician provider (e.g., NP, PA) and receive the 100% physician fee.
    • The location can be at the physician’s office, a satellite clinic, facility, or patient’s home.
    • During the first visit, the physician must evaluate the patient and write a care plan.
    • Follow-up visits by the NP can be billed as “incident to” as long as the same problems are addressed. The physician’s NPI number is used to bill for the service.
    • Incident to billing is reimbursed at 100% of the physician rate. If the same patient is seen for a new problem by the NP (or PA), the visit is billed under the NP’s (or PA’s) NPI, receiving approximately 85\% of the physician rate.
  • Medical Coding and Billing: Every time an NP bills Medicare, Medicaid, or a health insurance plan, a claim must be submitted electronically. The claim (superbill) must contain both the ICD-11 diagnosis code(s) and CPT code(s). Missing ICD-11 or CPT codes lead to claim rejection; must resubmit with required information; services must have medical necessity.
  • What Is the ICD-11 Code?: The ICD-11 code indicates the patient’s diagnosis as defined by the International Classification of Diseases, 11th edition (WHO, 2022). Each disease has a specific ICD-11 code.
    • Exam Tip: ICD-11 is used for diagnosis codes; CPT codes are used to bill for outpatient procedures/services; both codes are required for each bill.
  • What Is the CPT?: A five-digit code or alphanumeric code (letter with digits) used to identify medical procedures (e.g., suturing, incision and drainage) and other medical services. Maintained by the AMA.
  • What Are Evaluation and Management (E&M) Service Codes?: Used to bill for patient visits; part of CPT. If an E&M code is missing, reimbursement may be denied. E&M codes are based on the time or total time of the patient encounter, including: face-to-face time, record review, examination, history taking, patient education, ordering tests/medications, referrals, and documentation.
  • Health Technology: Telehealth and Telemedicine:
    • Telehealth encompasses a broad range of services and technologies to extend access, capacity, and delivery of care, including live videoconferencing, remote patient monitoring, and mobile health (portals, apps). It is not restricted to clinical services and can include provider training and continuing education.
    • Telemedicine is a subset of telehealth involving remote clinical services via secure audio/video connections; commonly used for chronic disease management, medication management, follow-up visits, and specialist consultation.
  • HITECH Act (2009): Incentives for adopting electronic health records (EHRs) and supporting technologies, with penalties after 2015 for providers/entities not adopting EHRs; strengthened HIPAA security and privacy enforcement.

Health Insurance Landscape and Policy Milestones

  • The Affordable Care Act (ACA, 2010): Expanded health insurance coverage; prohibits insurance companies from denying coverage for preexisting conditions.
  • Consolidated Omnibus Budget Reconciliation Act (COBRA, 1985): Continuation of coverage for preexisting group health insurance after job loss; typically 18 months, up to 36 months in some cases.
  • Managed Care: Includes HMOs and PPOs; structures differ in provider networks and referral requirements.
  • Health Maintenance Organizations (HMOs):
    • PCP as gatekeeper; patients pay a copay per visit; physicians are paid a set monthly fee per enrolled patient.
    • Referrals often required for specialists; in-network coverage is emphasized; out-of-network care may be limited or not covered.
  • Preferred Provider Organization (PPOs):
    • Patients may see any provider within the network without a PCP referral; typically higher costs than HMOs; more freedom to choose specialists.
  • Medicare and Medicaid Overview: Both programs are under the Centers for Medicare & Medicaid Services (CMS) within DHHS.
    • Medicare Part A: Inpatient hospitalization, hospice, home health, skilled nursing facility (SNF) care; covers medically necessary services; does not pay for custodial care.
    • Medicare Part B: Outpatient services, labs and imaging, durable medical equipment, second opinions, dialysis, ambulance; voluntary with monthly premiums; covers preventive services; excludes most eyeglasses/hearing aids/dental care and most prescription drugs (with exceptions).
  • Medicare Part B Preventive Services (selected list): Abdominal aortic aneurysm screening; annual influenza vaccination; Pneumovax/Prevnar 13 (lifelong); screening mammography (annually at intervals); Hepatitis B vaccine for at-risk individuals; Hepatitis C screening for high-risk individuals; colorectal cancer screening (colonoscopy every 10 years or flexible sigmoidoscopy every 5 years depending on risk); routine Pap smears (every 1–2 years depending on risk); prostate cancer screening (DRE and PSA annually); bone density testing (every 24 months if at risk); HIV and other infectious disease screenings (annually); annual physical exams; smoking cessation counseling and treatment; alcohol misuse screening and counseling; diabetes screening (twice yearly if at risk); cardiovascular disease screening.
  • Medicare Advantage (Part C): Plans cover both Part A and Part B, and some plans include prescription drug coverage; administered by private insurers approved by Medicare.
  • Medicare Part D: Prescription drug benefit; eligibility tied to Part A/B; formulary lists define covered drugs; nonformulary drugs may require out-of-pocket payment.
  • Medicaid: Federal and state matching program under Title XIX; provides health insurance for low-income individuals and families; covers children, pregnant people, adults, seniors, and individuals with disabilities; includes mental health and substance use treatment; maternal and infant health programs; currently the single largest payer for mental health services in the U.S.; covers contraception, family planning, and related services.
  • Children’s Health Insurance Program (CHIP) and CHIPRA 2009: Covers uninsured children (infancy to adolescence) and pregnant patients.

Exam Cues

  • ICD-11 codes are diagnosis codes; CPT codes are for outpatient procedures/services; both are required for each bill.
  • "Incident to" billing: used for Medicare outpatient services by nonphysician providers billed under the physician’s NPI; 100% physician rate for follow-up visits addressing the same problem; 85% for NP/PA when billing under their own NPI for new problems.
  • E&M coding is time-based and requires documentation of the encounter; missing E&M codes can lead to non-reimbursement.
  • Telehealth/Telemedicine expansion is tied to reimbursement policies and policy updates; staying current with CMS codes is essential.