Just Because You Can Perform a Medical Service, Does Not Mean You Should!

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Ever since the new year began, this author/consultant has been barraged with calls, from certified wound care nurses, nurse practitioners, and physical therapists, regarding job offers and work they would like to perform. At first, these calls appeared to be one-offs, but even today they continue at a rapid rate. In fact, this author/consultant also received a personal email that verified at least one of the reported scenarios. Therefore, this Business Briefs will address some of these situations to convince readers that just because you can perform a medical service, does not mean you should.

First, let us consider the email that this author received. It was from an organization that applies cellular and/or tissue-based products (CTPs) for skin wounds to patients in their homes. The email said if a physician wrote the order for the application of a CTP, the organization would send a nurse to the patient’s home to apply the product. Although there are many concerning facets of this model, this author is most concerned that nurses are applying CTPs, which is a surgical procedure. Performing surgical procedures is not in a nurse’s scope of practice.

Now, here is a synopsis of the many calls received from wound care nurses.

1.    “I have been offered a job from a physician’s practice. The physician wants me to travel to his patients’ homes and provide wound care, including the application of CTPs. The physician will use his NPI number to bill Medicare Part B for my work. The physician will pay me a very good salary. Is that a compliant model?”
 
Let us dissect this scenario:

• Providing wound care is in the nurse’s scope of practice.
• Performing surgical procedures, such as the application of CTPs, is not in a nurse’s scope of practice.
• Physicians cannot bill for any services performed by a nurse in the patient’s home when the physician is not present.

2.    “I have been offered a job from a physician’s practice. The physician wants me to travel to skilled nursing facilities (SNFs) and provide wound care, including the application of CTPs. The physician will report his NPI number on claims, submitted to Medicare Part B, for the work that I provide and for the CTP applied. I thought patients in SNFs are covered by Medicare Part A. The physician offered to pay me a significantly better salary than I currently receive at the hospital. Is this arrangement compliant?”
 
Let us think about the pitfalls of this arrangement.

• Providing wound care is in the nurse’s scope of practice.
• Providing nursing care to patients in SNFs is included in Medicare’s Part A SNF Consolidated Billing (CB) Payment System. If an outside nurse provides service in the SNF, the nurse should have a contract with the SNF and should receive payment from the SNF.
• Performing surgical procedures, such as the application of CTPs, is not in a nurse’s scope of practice.
• Billing Medicare Part B for the CTPs applied to patients in a SNF is not allowed during the Medicare Part A stay. While patients are receiving skilled care in a SNF, the SNF must purchase CTPs and cannot be separately billed to Medicare. Once the SNF purchases a CTP for a patient, a physician can apply it, but can only bill Medicare Part B for the application, not for the CTP.

The following is a typical call I have received from many nurse practitioners (NPs). “I have been offered a job by a physician’s practice. The physician wants me to perform debridement and to apply CTPs to patients in SNFs. The physician wants to pay me a salary and to allow his billing service to use my NPI number to bill for the work I perform in the SNFs. I am not sure that Medicare Part B should be billed for these services.”
 
The NPs are correct for the following reasons:

• It is odd that the NPs are not first providing wound assessments and conservative care.
• NPs should verify if surgical debridement is in their scope of practice. If yes, and if all the debridement coverage requirements are met and documented, the billing service could bill Medicare Part B for the NP’s surgical debridement.
• Selective debridement is the most common type of debridement performed in a SNF and is in an NP’s scope of practice. However, selective debridement (97597–97598) is included in the SNF CB payment system. The physician’s billing service cannot bill Medicare Part B for selective debridement during a patient’s covered Medicare Part A stay. Instead, the physician’s practice should establish a contract with the SNF and should bill the SNF for the selective debridement performed by the NP.
• NPs should verify if the surgical application of CTPs is in their scope of practice. If yes, and if all the CTP coverage requirements are met and documented, the billing service can bill Medicare Part B for application of the CTP, but not for the CTP itself. The SNF CB payment system requires the SNF to purchase the product, and the SNF cannot separately bill Medicare for it.
• Last, but not least, physical therapists in private practice are questioning if they can purchase CTPs, apply them, and bill Medicare Part B for the work and for the product. The easiest way to explain the answer they do not want to hear is:
• Surgical procedures, such as surgical debridement and the application of CTPs, are not in a physical therapist’s scope of practice.

Example: If included in the plan of care, and if the coverage criteria are met and fully documented, physical therapists can perform selective debridement, which is considered a medical procedure. However, physical therapists cannot perform surgical debridement, or excisional debridement (which some hospital coders inappropriately try to get therapists to document.) NOTE: When the American Medical Association revised the debridement codes, they were very careful 1) to place the surgical debridement codes in the surgical section of the Current Procedural Terminology (CPT)¹ book and 2) to preserve the selective debridement codes in the medical section of the CPT book. This allowed the therapists to perform the level of debridement that is in their scope of practice.
 
Because the application of CTPs is also a surgical procedure, the application codes are found in the surgical section of the CPT book and can only be performed by physicians or other qualified healthcare professionals. Therefore, physical therapists should not be tempted to purchase and apply CTPs.

In Summary

This author hopes these scenarios help you understand that just because you think you can do certain medical work does not mean that you should. Remember: If it sounds too good to be true, it is probably not true, and may even lead to false claims.

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com.   
 

Reference
1. Current Procedural Terminology is a registered trademark of the American Medical Association.