Should I hire a PA or NP or RN? That's a question a reader asks in this submitted story:
Happy, I came across a first the other day. I requested records from a subspecialist office in my town for a patient I was taking care of. In my town many PAs and NPs are used as data gatherers for the physicians. Their role involves nothing else. Templates in hand that guarantee a full level five consultation for every opinion asked. Their use in this capacity is entirely a function of the rules of the fee for service payment model we currently live in. It's easier to send a PA or NP to do all the data gathering and examination requirements necessary to collect a level five consultation visit than it is to spend an hour doing it themselves. Time better spent doing higher paying CPT codes. So I was not shocked to see a subspecialist outpatient clinic note, in template form, filled with all the requirements necessary to obtain a level five out patient office visit. Filled with review of systems and physical exam components that most internists don't even perform on routine office visits.
But there it was, in all it's glory. A complete outpatient follow up exam. A level five on a stable follow up exam. Who's documentation was performed by an RN. Not a PA. Not an NP. But an RN. With well placed "Per Dr Subspecialist" scattered in every possible section of the complete level five clinic note in order to get paid for "work done". You see, under current rules, RN's can not bill Medicare and get paid. But you get around that, apparently, by having them do all the data gathering and document "per Dr Subspecialist"
Wow. I'm impressed! I know this is all a documentation game. It looks like the data gathering role once delegated to the PAs and NPs is creeping into the RN world as well. It seems to me, as long as you clarify, "Per Dr Subspecialist" you could have a highschool student taking down the history and just document "per Dr Subspecialist" and all the requirements are met to get paid.
It's quite possible the role of data gatherer for PAs and NPs, currently being used in this capacity all over this great country of ours may go the way of the dinosaur, in favor of questionnaire specialists looking for a summer job to pay for their school outfits.
First it was MD doing the work. Then it was PAs and NPs. Now it looks like it's RNs. Soon, LPNs. Before long, high school students will be gathering the data.
With bundled care coming our way, we could have 1/2 as many physicians supervising hundreds of low paid high school students with questionnaires in hand. I imagine myself as a third year medical student presenting to the attending. I gather a ton of data. I have no idea what any of it means, but I look up in awe to the doctor who knows what it all means, instantly. Without even hesitating.
That's the future of our health care. Good bye NPs. Good bye PAs. Good bye RNs. Goodbye MDs. Hello high school students.
Addendum:
Under current Medicare rules, the only components that can be used for billing purposes from a medical student note is the review of systems and the past medical family and social history. HPI cannot. Physical exam cannot. Neither can medical decision making. The only folks that can bill for HPI and physical exam are MD, PAs and NPs. Unless of course you have an RN doing it with documentation stating "per Dr subspecialist".
at one well known medical establishment they call these RNs "Physician Extenders".
ReplyDeleteA level five on a stable follow up exam would never pass a Medicare audit, even if the specialist wrote a 500 page novel for documentation. There's that little bugaboo called "medical necessity" that gets 'em every time. Not to mention medical decision making, which won't get them a five on a stable follow up.
ReplyDeleteThat's all right - the money they saved using an RN to document will hopefully pay for their legal fees when Medicare finally audits them.
It is rather pointless to pay for something that can be done cheaper or redone.
ReplyDeleteAssessment is correlated with the level of skill and knowledge of the physician, I doubt that if you don’t know a disease is quite difficult, to ask for certain symptom, not mentioning travels, kind of work, data that can be related to the illness itself, and remember patients don’t always say the most valuable symptoms, they just yell what bothers them which is, 90% of it medically irrelevant, I prefer a focused assessment correlated with the current illness than a ton of info, personally my assessment is mine, physical exam too, is to risky just to copy paste something that someone else wrote.
What about the physical exam can you distinguish a paradoxical r2 desdoblation between a 3r sound?, noticing 4r, 3r sounds, noticing A waves as venous sign?, using physical exam to determine a knee lesion, of ligamentous lateral? distinguish a dizziness, with Romberg maneuver correlating it with the nigtasmus to locate where is the alteration. Examining a reflex even that is something that requires certain level of skill, I’m doubtful are those things leached on nursing career on the States?