AGACNP-1 Sessions 1&2 Scope of Practice, Billing & Coding, Health Promotion Questions and

AGACNP-1 Sessions 1&2 Scope of Practice, Billing & Coding, Health Promotion Questions and Role of AGACNP- Consensus Model No uniform model across states. Each states independently determines APRN legal scope of practice & criteria for certification. Licensure Granting authority to practice Accreditation Formal review & approval by a recognized agency of edu. or certification program. Certification Formal recognition of knowlege, skills, & experience demonstrated by achievement of standards identified by the profession. Education Formal preparation of APRNs in graduate degree-granting programs. Role of AGACNP vs. other NP Roles AGACNP care for "physiologically unstable, technologically dependent, patients that are highly vulnerable to complications." Scope & Standards of AGACNP Practice (AACN -Collect PT data -Analyze assessment data & determine dx -ID expected pt outcomes -Dev. & implement plan of care -Prescribe interventions -Eval. pt progress Quality Indicators/Outcomes -PT & family satisfaction -Rate of adverse events -Complication rate -Adherence to d/c plan -Mortality rate -LOS Synergy Model Core Concept Needs & characteristics of PTs & families influence characteristics or competencies of APRN Each indiv. characteristic is further delineated by levels of complexity or intensity Synergy Results when a pts needs & characteristics are matched with the APRNs competencies Synergy: PT Characteristics -Resiliency -Vulnerability -Stability -Complexity -Resource Availability -Participation in care -Participation in decision-making -Predictability ( allows one to expect a certain trajectory of illness) Patient Characteristics: Resiliency Capacity to return to a restorative level of fxn Patient Characteristics: Vulnerability Susceptibility to actual or potential stressors Patient Characteristics: Stability Ability to maintain a steady state of equilibrium Patient Characteristics: Complexity Intricate entanglement of 2 or more systems Patient Characteristics: Resource Availability Extent of resources the pt, fam., & community bring to the situation Patient Characteristics: Participation in Care Extent to which a pt & fam engages in aspects of care Patient Characteristics: Participation in Decision-Making Extent to which pt & fam. engage in decision-making Patient Characteristics: Predictability Summative characteristic that allows one to expect a certain trajectory of illness Synergy: Assumptions Nurses create an environment of care Impact areas are interrelated & may change as a fxn of experience, situation, setting Nurses work to optimize outcomes Nurse bring their background to each situation, various levels of edu., knowledge, skills, experience. Synergy: Nurse Characteristics -Clinical Judgement -Clinical Inquiry -Collab. -Learning Facilitator -Caring Practices -Response to Diversity -System thinking -Advocacy/Moral Agency Nurse Characteristics: Clinical Judgement -Clinical reasoning -Decision making -Diagnostic reasoning Nurse Characteristics: Advocacy & Moral Agency -Working on another's behalf -Serving as a moral agent to ID & help resolve ethical & clinical concerns Nurse Characteristics: Caring Practices -Responsiveness to the uniqueness of pt & fam. -Create a compassionate environment -Promote comfort -Prevent suffering Nurse Characteristics: Collaboration Intra- & Inter-professional work w/ colleagues & community Nurse Characteristics: Systems Thinking Managing environmental & system resources for pt/fam. w/in or across health care system Nurse Characteristics: Response to Diversity Recognize, appreciate, & incorporate differences into provision of care Nurse Characteristics: Clinical Inquiry -Questioning & evaluating practice -Creating practice change through research Nurse Characteristics: Facilitator of Learning -Learning for pt/fam., staff, HC team members -Formal & informal Assumptions of Synergy Model -The whole person must be considered -Each pt, fam., community contribute to context for nurse-pt relationship -Patients are described by a number of characteristics -Nurses are described by a number of dimensions -Nursing goal to restore a pt to optimal level of wellness as defined by the pt Synergy: Clinical Judgement -Heart of nursing -Art & science of decision-making -Providing clinical expertise -Diagnosis -Planning -Effective Implementation & eval of interventions approp. to complexity of probs. & resources of the system -Predict clinical pic. & dev. proactive & preventative interventions to manage clinical outcomes Synergy: Clinical Expert -Utilize intuition, reflection, & methods of knowing the pt -Relies on analytic rules for clinical judgement, & uses intuitive grasp which has a deep understanding of the whole situation Role of ACNP -Clinical Inquiry -Collab. -Systems thinking -Caring Practices -Response to Diversity -Advocacy/Moral Agency -Facilitator of Learning -Clinical Judgement Clinical Judgement = Clinical Expert Clinical reasoning, which includes clinical decision-making, critical thinking, global grasp of situation + Nursing skills acquired through process of integrating formal & experiential knowledge, & EBP guidelines. AGACNP Study of Practice -Elicits comprehensive H&P -Dev. DDX -Orders & interprets approp. diagnostic studies -Collaborates with physicians & other HC team members -Prescribes meds & therapeutics in collab w/ HC team -Initiates referrals & performs consults -Performs invasive procedures AGACNP Medicare Billing Reimbursement -Provider must have NPI -Medicare Part B (Eval. & mngmnt, & procedures) -Services must be w/in state scope of practice for NP -Services must be medically necessary -Reimbursement levels @ 85% physician's fee schedule rate -Insurance company reimbursement- NP must be approved (credentialed) participant (varies between companies & states) Medicare Part A Hospital services -room -food -meds -tests Medicare Part B Provider services -examination -procedures -surgery -coordination of care -counseling "Incident to" Billing DOES NOT EXIST IN HOSPITAL SETTING -part of shared billing AGACNP Billing for Reimbursement -Not required for all NPs -NPs employed by group working w/in a hospital may bill for services -May bill under their own NPI for procedures performed when credentialed for procedure (i.e. central lines, ET tubes, etc.) -Medical necessity of procedure MUST BE DOCUMENTED -NPs working in a group may bill for time spent w/ PT When AGACNPs Cannot Bill for Reimbursement NPs who are employees of the hospital may not bill Coding Components for Chart Billing Evaluation & Management (E/M) International Classification of Disease 10 (ICD-10) Evaluation & Management (E/M) Detailed requirements for how many elements must be included in note -Follows H&P & SOAP note format Levels depend on how comprehensive assessment & note are: -Level of decision-making & complexity -Time spent w/ pt International Classification of Disease 10 (ICD-10) -Used for coding & billing in US -Used for statistical tracking & quality monitoring by CDC Shared Visit -Proper documentation by BOTH MD & NP -Billed under MD NPI # -NP must be contract or employee of same co. as billing MD -100% of MD fee reimbursement eligible -MD/NP face-to-face visit must BOTH occur on SAME DAY -Documentation must clearly indicate BOTH MD/NP involvement/participation -DOES NOT APPLY TO CC SERVICES Charting Elements of Shared Visit History Physical Medical decision-making Appropriate use of Critical Care Time -Only used when "high probability of imminent or life-threatening deterioration" & impaired organ fxn -Care req. complex medical decision-making Billing for Critical Care Time -Code 99291 first 30-74min (must be 30min) -Code 99292 after 74min -Must be employee of a group, NOT THE HOSPITAL (determined by who pays salary) Critical Care Documentation Include: -Organ system(s) at risk -Therapeutic interventions -Diagnostic tests performed/ordered + rationale -Critical findings -Likelihood of life-threatening deterioration w/o intervention -Time spent providing CC 9need to be immed. avail. to PT) Critical Care ICD-10 Coding Include: -Primary Dx -Underlying cause -Comorbid conditions Procedure Billing w/ CC Code If CC code used, cannot bill separately for: -CO measurement & interpretation -CXR interpretation -Blood draw -Interp. of other tests stored on computers (EKG, ABG, CBC, etc.) -Pulse ox -Vent. mngmnt -Vasc. access procedures -TransQ pacing CC Code Separate Billing If CC code used, can separately bill for: -CPR -ETT Intubation -Central line insertion Healthy People 2020 Leading Health Indicators 1. Access to Health Services 2. Clinical Preventive Services 3. Environmental Quality 4. Injury and Violence 5. Maternal, Infant, and Child Health 6. Mental Health 7. Nutrition, Physical Activity, and Obesity 8. Oral Health 9. Reproductive and Sexual 10. Health 11. Social Determinants 12. Substance Abuse 13. Tobacco HP 2020: Access to health Services 1 in 4 pts do not have PCP or health center where they can receive regular services 1 in 5 Americans do not have med. insurance -Disease & disability prevention -Detection & tx of illness -Increase quality of life -Reduce likelihood of early death HP 2020: Environmental Quality Air quality (ex. pollution, secondhand smoke, lead, CO, chemicals) Safe air, land, water are fundamental LHI: -Air Quality Index 100 -Children exposed to secondhand smoke HP 2020: Injury & Violence MVCs, homicide, domestic & school violence, child abuse, neglect, suicide, unintentional drug OD HP 2020: Clinical Preventative Services -Routine disease screening & scheduled immunizations -Children receiving recommended doses of DTaP, polio, MMR, Hib, HepB, varicella, PCV vaccines by age 19-35 mo. -Regular colorectal screening -HTN mngmnt -DM mngmnt (A1C9) HP 2020: Maternal, Infant, Child Health Healthy birth outcomes & early ID & tx of health conditions among infants -31% of women suffer pregnancy complications -depression -C-section -Associated w/ obesity LHI: -All infant deaths (higher than 46 other countries) -Total preterm live births (12% each yr.) HP 2020: Mental Health -Suicide -Adolescents w/ major depressive episode w/in past 12mo. -Strong link btwn mental illness & r/f health conditions including DM, HTN, stroke, heard disease, CA HP 2020: Nutrition, Physical Activity, & Obesity Diet, reg. physical activity, achieving & maintaining healthy weight -Achieve & maintain healthy weight -Reduce r/f heart disease -Reduce r/f certain CA -Strengthen muscle, bones, joints -Improve mood & eneergy LHI: -Obesity in all age groups -Adults meeting physical activity objectives -Daily veggie intake HP 2020: Oral Health Tooth brushing Regular dental check-ups LHI: -Children, adolescents & adults who visited dentist w/in past yr -Dental caries -Periodontal disease -Cleft palate -Oral & fascial pain -Oral & pharyngeal CA