Efficient Use of Advanced Practice Providers Promotes Value-Based Payment System in Urology

The move toward a value-based payment system will reward providers for resource utilization tied to superior outcomes and will encourage directing low- and moderate-risk patients to advanced practice providers (APPs), according to Rick Rutherford, CMPE, CHA, Director of Practice Management for the American Urological Association (AUA). He discussed the role of APPs at the 2015 AUA annual meeting.

Training for Urology Practice

The effective use of APPs, including advanced registered nurse practitioners (NPs) and physician assistants (PAs), will optimize revenue for providers while maintaining the overall quality of care provided by a urology practice.

“Most of them have general training, so they will be prepared to do a lot of things that you don’t need them to do, like throat cultures,” said Mr Rutherford. “That’s a useful skill, but it’s not needed in a urology practice.”

The most common approach to training APPs for a urology clinic is on-the-job observation of urologists in the practice. Courses, seminars, webinars, and other forms of traditional classroom-type learning are available in some cases, but most APPs learn by observing and performing activities under the direct supervision of urologists.

APPs have many of the same prerequisites as physicians, including state licensure, Medicare enrollment, hospital privileges, professional liability coverage, a National Provider Identifier number, and credentialing by commercial insurers. The scope of practice for an APP depends on several factors. The State Board limitations vary from state to state.

“It’s important to be aware of these limitations,” said Mr Rutherford. “They can change over time, so don’t assume that State Board policies are the same ones that applied when you hired your first advanced practice provider.”

Other factors that will influence the scope of practice for an APP are the comfort level of the supervising physicians, and the limitations dictated by liability coverage.

“When a nurse practitioner goes to a hospital for consults, there is always one or two primary care physicians or internists who say, ‘No, I don’t want this person to see my patients. I want the doctor,’” Mr Rutherford noted. “My typical response is, ‘That’s fine, our nurse practitioner can see your patient in 2 hours. The doctor can see them tonight about 8 o’clock, after he’s finished with his office, and he’s making rounds. Which one do you want?’ It only takes 1 or 2 consults for the referring physician to come away impressed with the skill of a well-trained advanced practitioner.”

Although scope-of-practice laws vary by state, a growing number of states are granting APPs full practice status. Essentially, practitioners in those states can see patients independently, said Mr Rutherford. Reduced-scope states allow practitioners to engage in at least 1 element of clinical practice, but they require a signed collaborative agreement with a physician. Approximately 20% of the states still have restricted laws that require supervision, delegation, or team management by a physician for APPs.

According to recent data from the Medical Group Management Association, surgical and nonsurgical NPs earn approximately $100,000 annually. Surgical PAs earn $115,000 to $120,000 annually, and nonsurgical PAs earn approximately $100,000 annually.

APPs Enhance Revenue

Mr Rutherford and his colleagues at the AUA have developed suggestions and recommendations for enhancing the revenue generated by APPs. Their ideas fall under the 2 broad categories of “efficiency enhancers” and “revenue enhancers.”

Efficiency enhancers include the direct entry of physician orders into an electronic health record (EHR) system, triage assistance for office phone calls, first responder service for after-hours calls, postoperative follow-up visits, patient support groups, and participation in clinical research.

Mr Rutherford noted that “meaningful use” regulations require trained personnel for making entries into EHR systems. As for telephone triage, it should address clinical issues, such as deciding whether a patient should come to the office or if the patient merely requires a prescription refill.

The first responder activities can extend beyond after-hours periods. Some practices use APPs as first responders during their regular office hours. For example, the approach allows urologic surgeons to spend the entire day in the operating room rather than taking time to address questions that an APP can answer just as easily without delay.

Among potential revenue enhancers, maximizing APPs for office visits that are billed as “incident to physician services” is probably the most familiar.

“Established patients can be seen by the nurse practitioner or physician assistant just as appropriately and efficiently without the physician seeing them every time,” Mr Rutherford pointed out. “In some of the subspecialty areas, such as incontinence and sexual dysfunction, nurse practitioners and physician assistants can easily see patients for many of the routine clinic visits.”

Revenue enhancers also comprise hospital consultations, independent or shared hospital visits, home care and telemedicine consultations, and surgical assistance.

Billing for APP Services

Medicare has specific requirements that services provided by PAs or NPs must meet to qualify for “incident to” reimbursement, according to Edna Maldonado, CPC, ACS-UR, Coding Coordinator for the AUA. One of the key requirements involves making a clear distinction between services provided “incident to” those of a physician and shared visits with physicians.

“The PA or NP must be employed by the physician group,” she said. “They can cover evaluation and management, minor office procedures, for example, Lupron injections, and chemotherapy administrations.”

The requirements as they pertain to patient evaluation and management depend on the APP’s scope of practice, as defined by individual states and practices.

“The physician must see the patient for the initial office visit,” said Ms Maldonado. “Thereafter, the physician may visit with the patient occasionally, and the PA or NP handles the follow-up. If a new problem occurs, the patient must be scheduled back with the physician.”

Integrating APPs into a plan of care requires thorough knowledge of Medicare administrative contractors’ expectations regarding the frequency of physician visits after the initial visit. The frequency must be medically appropriate for the patient’s condition.

“This changes every year, so it’s important for the practice manager or another designated person to look up the policies that pertain to nonphysician providers and see whether anything has changed,” said Ms Maldonado. “Standing orders or clinical protocols do not override these frequency decisions.”

For example, some Medicare administrative contractors have stated frequency requirements requiring that a patient see a physician every third visit. Changes in a plan of care, such as a change in prescription or a change in the dosage of the same drug, constitute a new plan of care and may invalidate the incident-to status of a clinic or office visit.

Beyond individual Medicare administrative contractor requirements, several general rules apply to APPs with respect to incident-to status. The visit must occur in the office. When the physician is present on-site, an incident-to visit with an APP can be billed at 100% of the physician rate, as long as the visit involves an established patient, a plan of care created by a physician, and occasional physician involvement in the care.

An incident-to visit can be billed at 85% of the usual rate when a physician is not on-site at the time. Hospital visits by APPs are always billed at 85%, unless the physician is also present, and home visits by APPs are always billed at 85% of the usual physician rate.

“It is essential that the billing personnel understand these rules, so that they know when these situations arise and how to bill appropriately,” said Mr Rutherford.

Involvement by APPs in diagnostic tests varies. APPs may administer diagnostic tests that are billable to Medicare, but they cannot supervise diagnostic tests that are billable to Medicare. The service provided by the APP must conform to the supervision requirements that are specific to the procedure code.

APPs can have responsibility for oversight and training for the Centers for Medicare & Medicaid Services Physician Quality Reporting System entries. One model allows APPs to evaluate incoming patients, to triage urgent cases to physicians, and to manage nonurgent cases themselves or to triage them to other APPs.

The AUA has not taken an official position on the involvement of APPs in invasive diagnostic or therapeutic procedures (eg, cystoscopy), said Mr Rutherford. Supervising urologists remain the “ultimate decision makers.”