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Anthony Cirillo

Care Coordination Has Positive Reimbursement Implications

By January 23, 2013

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The Medicare Physician Fee Schedule Final Rule, that was set to take effect Jan. 1, includes new codes that describe "complex chronic care coordination," a service typically provided by RNs. Though the rule will not allow separate billing for care coordination, some private insurers are likely to use the codes to reimburse providers directly for the service.

The American Nurses Association (ANA) noted in a release that "Such reimbursement policies for care coordination could expand the RN job market. They could also raise recognition for nurses performing this long-held, core professional standard and competency considered integral to patient-centered care and the effective and efficient use of health care resources."

This is good news for providers on a number of fronts. By offering care coordination services you not only drive revenue but you also become a more valued partner to hospitals in an accountable care organization.

The rule contains several other provisions that benefit nurses by:

  • Clarifying that certified registered nurse anesthetists will continue to be reimbursed for providing chronic pain management services in states where permitted by license.
  • Permitting advanced practice registered nurses to order portable X-rays.
  • Ensuring nurse practitioners and clinical nurse specialists can conduct the in-person encounters required for ordering durable medical equipment for patients.

The new Medicare rule calls for paying RNs for services intended to effectively manage patients' transitions from hospitals to other settings and to prevent complications and conditions that cause expensive hospital re-admissions. The rule also creates new payment codes for "care coordination" activities performed by RNs that reduce costs and improve patient outcomes, increasing likelihood of direct reimbursement for these services and potentially creating more RN jobs to fill this need. With up to 20 percent of Medicare patients re-admitted to hospitals within 30 days of discharge, more value is being placed on effective transitional care and care coordination.

"The American Nurses Association has been advocating for years that government and private insurers need to recognize nurses' contributions to transitional care and care coordination and pay appropriately for these essential services," said ANA President Karen A. Daley, PhD, MPH, RN, FAAN. "This Medicare rule is a giant step forward for nurses whose knowledge and skills play major roles in patients' satisfaction and quality of care."

ANA's 2012 report, "The Value of Nursing Care Coordination," highlights numerous studies showing the positive impact of nurse-managed care coordination. Studies show that care coordination reduces emergency department visits, hospital readmissions, and medication costs; lowers total annual Medicare costs; improves patient satisfaction and confidence to self-manage care; and increases safety for older adults during transitions between settings.

New payments will be awarded to nurse practitioners, clinical nurse specialists, certified nurse midwives, and other primary care professionals for "transitional care management" services provided within 30 days of a Medicare patient's discharge from a hospital or similar facility. To qualify for reimbursement, the primary care professional must: contact the patient soon after discharge; conduct an in-person visit; engage in medical decision-making; and provide care coordination. Care coordination involves effectively communicating and delivering a patient's needs and preferences for health services and information among a continuum of health care providers, functions, and settings.

This is one true shift, a little peek, into what happens when wellness gets rewarded. Smart providers should start to anticipate the next set of services and professions that will fall in line and plan accordingly to offer them.

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