Many attending physicians and medical directors already employ or have worked with advance practice nurses or physician assistants. Given the shortage of primary care physicians, especially in the area of geriatrics, CMS has been willing to support a growing workforce of what they refer to in the regulations as “Non-Physician Practitioners” or “NPPs”.
Advance practice nurses may work directly for physicians seeing our patients in our LivingCenters, be employed by Golden Living directly, or work for a third-party (Trident Mobile Services and PRIME by AseraCare are two examples of organizations which may provide Nurse Practitioners to our facilities). NPPs who are not employed by the attending physician need to have a collaborative agreement with the attending physician or LivingCenter Medical Director. There are some state variations in scope of practice of NPPs.
Can they do the initial H&P?
CMS allows physicians to work collaboratively with these NPPs. When a patient is admitted to a SNF, the patient’s initial comprehensive H&P must be done by a physician. This particular visit may not be delegated to an NPP. CMS is clear on this issue, as in CMS communication below.
Physician Required and other Medically Necessary Visits in SNFs:
Under 42 C.F.R.§483.40(c)(3), all required physician visits must be made by the physician personally and cannot be delegated. A required physician visit includes the initial comprehensive visit in a SNF and every alternate required visit thereafter, as required in 42 C.F.R. §483.40(c)(4). The initial comprehensive visit in a SNF is the initial visit during which the physician completes a thorough assessment, develops a plan of care and writes or verifies admitting orders for the resident.
Under 42 C.F.R. §483.40(c)(1), the initial comprehensive visit must occur no later than 30 days after a resident’s admission into the SNF. Further, under 42 C.F.R. §483.40(c)(4) and (e), the physician may not delegate the initial comprehensive visit in a SNF.
But does that mean that an NPP may not see the patient prior to this initial H&P? No. If there is medical necessity, where the state laws also permit this, an NPP may see the patient before the first physician visit. The CMS communication continues:
Non-physician practitioners may perform other medically necessary visits prior to and after the physician’s initial comprehensive visit.
This makes sense medically, if not semantically. A medically necessary “subsequent visit” may be executed by the NPP and billed, even prior to the “initial visit.” So for example, if a patient is admitted from the hospital, and the doctor cannot see the patient in several days, but the patient needs to be evaluated, this visit may be done by the NPP. The visit needs to be medically justifiable (generally not hard to do for patients who are new and complex) and the documentation must support the billing code. It is billed as one of the “subsequent” visit codes.
The NPP may be very complete in evaluating the patient, but what the surveyors do NOT want to see is an NPP doing what is considered to be an initial visit, filling out an H&P form, and then having the attending just co-sign the note. Regardless of how that visit is billed, this can be interpreted as the NPP “doing the initial visit.” The spirit of the regulation is that there is an understanding that the NPP is involved in care, but supervised by the physician. The physician is responsible for the initial evaluation of the patient and coordinating the care.
Are there any exceptions to this at all?
There is a specific CMS clarification which states that for “straight Medicaid” patients, when allowed by the State, may be seen initially by NPPs. This may also apply to private pay. Most insurance companies expect physicians to comply with CMS Medicare standards while seeing their patients. Given that it is can be difficult and time consuming to confirm exact insurance status on rounds, and that most patients are at least partly Medicare patients, I would recommend that the physician always be the one do the initial H&P to avoid accidentally making a mistake.
Does this mean that if the NPP writes a very complete note and the physician seeing the patient the next day needs to write their own note repeating everything?
Not exactly. The physician must write an H&P, the work must be done by the physician, and the documentation must justify the initial visit severity code. A word of caution, if the verbiage is identical to the NPP wording, or there are other indicators that make it look like the doctor really was not involved in care, then that physician could be at risk in a review.
Can NPPs see my patient in between my visits?
Again, so long as visits are medically necessary, they may see your patients for subsequent visits. This is very important for patients who are in need of closer medical supervision, as discussed above regarding frequency of physician visits. They may also, when allowed by State law, make alternate regulatory visits as well. It is not permissible to bill for multiple visits on the same day, regardless of whether the visits are made by a physician, NPP, or both. If you are working in a collaborative fashion with an NPP (for example, one who is a third-party NP), it would be wise to communicate regarding on which days you’re both going to make rounds, and whom you will see, in order to avoid any billing conflict.
Advance practice nurses and physician’s assistants can be a great help to the physician and an integral part of patient care. As long as we observe the regulations involved, this can result in a significant improvement in our ability to care for our increasingly complex patients.
 CMS, Center for Clinical Standards and Quality/Survey & Certification Group, Communication to State Survey Agency Directors, Physician Delegation of Tasks in Skilled Nursing Facilities (SNFs) and
Nursing Facilities (NFs) S&C: 13-15-NH, March 8, 2013, p. 2.
 Ibid, p. 2.
 MLN Matters: SE1308 Revised, March 8, 2013, p. 3. Where the reference mentions “NF’s” as opposed to “SNFs” this is in reference to Medicaid patients. The actual regulation is patient coverage, not facility specific.