Forum - Questions & Answers

Jul 20th, 2015 - Gemerson 1 

When a provider based physician office brings in student nurses-what can they do?

Question=When a provider based physician office brings in student nurses, and student APRN's (APRN's technically have a basic nursing degree)-what can they do under Medicare in the office setting? Per your earlied article-"NP or PA student services may not be billed by their supervising NP or PA. It is not permissible to bill for the services DOCUMENTED by any student." But what if Students are participating in the CARE just like the PT/OT Mcare LCD states.

We have a policy that all students who document use a temporary EHR, so that nothing they do can be used for billing purposes, it then never becomes part of the permanent record. So vitals for instance could be done by students, but our interpretation is that they must be reperformed to be included as part of the E/M History.

In reality though-students need to learn vitals and administering vaccines and injections, or perform urine dipsticks and or throat swabs. You need to charge for an injection and can only give it once, so how can nursing students in the office get experience in a provider based office if they are not allowed to perform any service that has a billable component to it?

Medicare -LCD (26884) Physical Therapy-.states-even for PT OT students-Services performed by a student (therapy student or therapy assistant student) are NOT REIMBURSED even if provided under “line of sight” SUPERVISION of the therapist.

However, Medicare states the services of a qualified professional ARE covered, even when a STUDENT IS PARTICIPATING IN THE CARE

To be covered when the student is participating in the care, the qualified professional must be present in the room and must:

•DIRECT the service, making the skilled judgment and assessment, and assume responsibility for the treatment;
•NOT BE engaged in treating another patient or doing other tasks at the same time (such as documentation); AND must
•SIGN ALL documentation appropriately. A student may also sign the documentation, but it is not necessary since the Part B payment is for the qualified professional’s service, not for the student’s services.

What is your stance on this to use this this guidance and interpret it as in the provider based office setting- for care the student participates in to be covered when:

The qualified professional (RN, APRN, PA or MD?) must be present in the ROOM, DIRECT the service, NOT BE engaged w/another patient, SIGN ALL documentation (withing their scope of licensure so RN nurse teaching nursing student)

Other wise we know per Medicare the physician in the Evaluation and Management levels, may refer only to students note of Review of Systems and Past Family and or Social History in his note.

We feel it is important to be part of the training process for our future nurses and perhaps retain some on the way.

Offices are reluctant to have them come on board because it is time intensive and they can't use them to document. Of course we want one process to follow for all insurances, and Medicare is the strictest and our ultimate guide.

Things we have that student nurses can do are:
1)Update medication lists
2) Update problem lists
3) Track and review information that may have occurred since the last encounter like Ancillary studies, laboratory values, Consultation notes.
4) Review and assist in update of health maintenance
5) Gather chronic disease management data
6) Provide education to patients

Would you recommend any of the below meeting the three criteria of present in the ROOM, DIRECT the service, NOT BE engaged w/another patient, SIGN ALL documentation.

A) Vitals
B) Vaccines
C) Swabs
D) Subcutaneous Injections

Any other suggestions for training or additional tasks?

Thanks-Double Edged sword

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