The Green Valley Fire District Community Services Division was formed in 2013, to combine a variety of functions and programs that are all directed toward providing specific services. In 2015, the District started Fire-Based Urgent Medical Service (FBUMS), using family nurse practitioners to provide medical crews with extra resources to manage non-emergent and urgent care calls. The District invested $120,000 to get the program operational and is currently operating with four part-time nurse practitioners.
These nurse practitioners are independently licensed practitioners with the responsibility of managing and coordinating health care in accordance with State and Federal rules and regulations and the nursing standards of care. They provide coverage between 8 a.m. and 5 p.m. five days a week. The Green Valley nurse practitioners evaluate patients and decide if emergency transport to the hospital is needed. The nurse practitioners provide urgent medical care for mild to moderate conditions to bridge the gap until the patient can see their own physician. They also can help manage a patient’s medication and prescriptions. Additionally, Green Valley residents can schedule house visits with the nurse practitioner if desired through the fire station.
The goal of nurse practitioner programs is to optimize resources and manage emergency responders and ambulances. As many as 25 percent of residents who call 911 for medical assistants do not require emergency care, but would frequently end up being transported to local hospitals as the only option was shown in a study by district Battalion Chief Dan Modrzejewski. Modrzejewski’s found that of 1,629 transports to the emergency department, 448 could have been treated at home by a nurse practitioner, rather than be transported to Tucson hospitals. These often expensive and unnecessary emergency room visits detract from community resources. In addition to the allocation of resources, it is financially beneficial to residents to use the program over visiting an emergency room. A hospital trip to the nearest Tucson hospital 30 miles away from Green Valley averages $3,000 to $4,000. A home visit from a nurse practitioner averages $300-$400, 10% of the cost of an emergency room visit.
Green Valley is a retirement community with a median age of 71.2. With an older population comes mobility issues that frequently make it problematic for locals to see their primary physician or to make it to an urgent care facility independently if needed. Often, the only option may be to call 911 for treatment for even minor issues with the elderly population served.
With securing licensing and requirements to satisfy Arizona State Health Department as an Unclassified Healthcare Institution to provide urgent care services Green Valley Fire District is able to treat patients on Medicare with credentialing under Arizona Health Care Cost Containment System and other insurance plans for payments to the nurse practitioners in their program. The program differs from others in that it has its own nurse practitioners on staff and are licensed to Green Valley Fire District nurse practitioners do not ride along with ambulance crews.
Procedural Terminology and Coding and Billing
Billing is a significant factor in providing documentation of nurse practitioner productivity. Under-billing for services means not maximizing revenue generating potential. There are no federal laws that define or limit how private insurers recognize or reimburse nurse practitioners. The Balanced Budget Act of 1997 officially recognized nurse practitioners as healthcare providers. Nurse practitioner billing can be accomplished under two options; independent or incident-to. Nurse practitioners use the same evaluation and management (E/M) service codes, International Statistical Classification of Diseases and Related Health Problems (ICD-9) diagnostic codes, and current procedural terminology (CPT) procedure codes as physicians.
Medicare Billing is done using either current procedural terminology codes or evaluation and management codes. Current procedural terminology codes are a systematic listing and coding for services performed by the provider that serves as the basis for health care billing. Currently, the American Medical Association (AMA) procedural codes are developed, maintained, under copyrighted by them. The consistent language used offers an effective standardization of communication that is consistent between practitioners, patients, and Insurers. Insurers use the current procedural codes to determine the amount of reimbursement to be paid to the practitioner.
Categories of third-party payers who reimburse for nurse practitioners include Medicare, Medicaid, commercial fee for service models, and commercial Managed Care plans. A concern surrounding billing is Incident To billing and independent billing for nurse practitioners service under a physician’s provider number. A nurse practitioner is eligible to acquire their own provider numbers and are able to submit bills under Medicare Part B for evaluation and procedures provided. Services provided by the nurse practitioner must be within the scope of practice in Arizona State and must be medically necessary. Medicare pays 80% of the patient’s bill for physician services and leaving the patient to pay 20%. Medicare reimburses nurse practitioner at a rate of 85% of the physician fee. Separate Centers for Medicare & Medicaid Services who contractor may have their own interpretation of Centers for Medicare & Medicaid Services rules, which may lead to some inconsistent. On the payer side, some may have different rules regarding nurse practitioner provider status and they would need to be consulted for clarification on individual bases.
Under independent billing, a nurse practitioner can bill for the level of care, time, diagnosis, and counseling provided to the patients. Medical billing and coding can be complicated and attention to detail is essential to maximize reimbursement and avoid inaccurate billing payer or patient. Accurate documentation is important to track the level of treatment provided by the nurse practitioner to be submitted for reimbursement form the provider. The documentation submitted can include the tests performed, examinations, diagnoses, treatment, and recommended a follow-up if needed. If the documentation is incomplete and unable to support the level of care being cited in the bill, or if the bill does not reflect the level of care provided to the patient, this could be an instance of over or under billing for services delivered.