Assignment: Reimbursement Issues For Nurse Practitioners

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Assignment: Reimbursement Issues For Nurse Practitioners

Assignment: Reimbursement Issues For Nurse Practitioners

Understanding the complex process of accurate coding and billing is essential to a sustainable practice. As NPs, we are ultimately responsible for ensuring all coding and billing is accurate for each patient seen. For this Discussion, you will search the health care literature and summarize a peer-reviewed journal article published within the last five years.

To prepare:
  • Select one of the following topics:
    • Applying for Medicare and Medicaid Provider Numbers
    • Application process for National Provider Identifier Number
    • Incident to billing
    • Coding-Evaluation & Management
    • Fraudulent billing
    • Billing Self-Pay patients
    • Managed Care Organizations
  • Conduct a search and select a peer-reviewed journal article published within the last five years related to the topic you selected.

Note: For this Discussion, all students are to avoid all written work, which reviews or outlines coding and billing at previous or current worksites as well as previous or current practicum sites.

By Day 3

Post a brief summary of the article you selected. Include the key reimbursement issue addressed and how they would impact the NP in a collaborative practice versus and independent practice. Discuss an ethical or legal implication(s) associated with your article.

That morning’s experience was a baptism of fire. Deserted were the laboratory and the academic work of the college. I never returned to them. On my way from the sick-room to my comfortable student quarters, my mind was intent on my own responsibility. To my inexperience it seemed certain that conditions such as these were allowed because people did not know, and for me there was a challenge to know and to tell. When early morning found me still awake, my naive conviction remained that, if people knew things—and “things” meant everything implied in the condition of this family—such horrors would cease to exist, and I rejoiced that I had a training in the care of the sick that in itself would give me an organic relationship to the neighborhood in which this awakening had come.

Reproduced from Wald, L. D. (1915). The House on Henry Street. New York, NY: Henry Holt.

In order for the APRN function to thrive in many situations, it may be necessary to generate revenue source. 
There are more options for APRN services to be billed, and APRNs must be aware of the problems associated in obtaining third-party reimbursement. 
When it comes to reimbursement, the APRN must be aware of variety of legal and financial difficulties. 
Reimbursement is complicated framework that involves state and federal regulatory concerns. 
For example, APRNs may only bill Medicare under the physician payment system provided they have legal authority to conduct the service in question under state law. 
Since states license APRNs, there is difference in the definition of an APRN, clarification on the question of legal power will be discussed under the definition of an advanced practice nurse. 
Billing rules are complex, spread throughout Federal and State legislation, and differ from payer to payer. 
Many insurers will follow Medicare guidelines, despite the fact that this fact sheet will cover Medicare billing restrictions. 
The APRN should keep in mind, however, that insurers may govern reimbursement in their own unique way.


Understanding the history of APRN reimbursement is crucial because it sets the stage for what follows. 
Only rural areas and skilled nursing institutions were eligible for direct APRN reimbursement from Medicare in 1990. 
Medicare expanded reimbursement for Clinical Nurse Specialists (CNS) and Nurse Practitioners (NP; as well as nurse anesthetists and nurse midwives, but these roles will not be covered in this fact sheet) to all geographic and clinical settings in 1997, allowing direct Medicare reimbursement to the APRN, but only at 85 percent of the physician rate. 
The American Nurses Association’s effective political action, which used outcome data to show how CNSs and NPs make difference in cost and quality, as well as political action alliances with specialty organizations and grassroots activities by local nurses, led to this victory.


This information sheet will provide an overview of reimbursement for advanced practice nurse services as well as billing difficulties. 
The regulatory landscape is complicated, and APRNs should be familiar with it in order to optimize reimbursement opportunities and explore billing options. 
It’s vital to remember that, in addition to federal billing requirements, each state has its own licensing authority for APRNs, which varies based on the jurisdiction where the APRN works. 
Each APRN will need to research their state licensing laws and consult with their billing specialists to determine how the billing regulations should be interpreted. 
As of the date it was produced, this fact sheet contained the best assessment of the APRN reimbursement difficulties. 
This information sheet is intended to serve as starting point for the APRN to become familiar with billing difficulties and opportunities, but it is not intended to be an authoritative paper on all billing concerns.
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