In 2009 the Wound Ostomy and Continence Nurses Society Board of Directors developed a strategic plan to guide the Society for the following three years. This ambitious plan included a mandate for the Public Policy Committee to develop an action plan and a section of this mandate included the following: “Expand reimbursement for WOC nursing services”. A task force of WOCN members from the Public Policy Committee as well as past leadership was called into action to address a work plan to meet the mandate of expanding reimbursement opportunities for WOC nursing services. A discussion of tactics as well as review of opportunities for WOC nurses to seek reimbursement was done in order to organize the work of the newly created Reimbursement Task force under the direction of the Public Policy Committee Chair, Suzanne Collins. The Reimbursement Task Force, headed by Jan Colwell, discussed reimbursement opportunities and road blocks. It became clear that reimbursement for some services a WOC advanced practice nurse provided was available in some settings and some locations. Other areas of discussion included:
- The variability of reimbursement for advanced practice WOC nurses (AP/WOC nurse), centering on the practice location (i.e. state), the setting (acute care versus outpatient care) and the general lack of understanding of these and other issues for the AP/WOC nurse.
- The need to provide information for the AP/WOC Nurse enabling this practitioner to start a discussion within their work area to see what reimbursement opportunities may be available.
- Examination of other specialty groups to see if they had pursued reimbursement options.
- The need to provide non APRN/WOCN members options for reimbursement.
- The lack of CPT codes related to ostomy care services.
Two work groups were formed; one to address the reimbursement options for the advanced practice nurse and another to address the reimbursement options for the bachelor's prepared WOC specialty nurse. The APRN work group consisted of Cecilia Krusling, Phyllis Kupsick, Nancy Scott and Jan Colwell. This group worked for over one year reviewing literature covering areas of reimbursement, including many government documents to obtain a clear understanding of Medicare reimbursement (as many private insurers follow the federal government's policies). The outcome of this work is the document: Reimbursement of Advanced Practice Registered Nurse Services. The purpose of the document is to provide the Advanced Practice Registered Nurse with information to understand the opportunities and challenges in acquiring reimbursement for professional services. This fact sheet contains the best interpretation of the APRN reimbursement issues as of the date it was written. It is hoped that this fact sheet will provide a starting place for the APRN to become acquainted with billing issues and opportunities, but is not meant to be an authoritative paper on all issues related to billing.
The second work group examined what opportunities for revenue capture might be available for the non APRN/WOC nurse. There were no other non APRN specialty nurses receiving reimbursement (with the exception of a minimal fee reimbursed for diabetic education), because of the federal requirement that reimbursement is limited to a nurse provider defined by Centers for Medicare and Medicaid Services (CMS) as a clinical nurse specialist, a nurse practitioner, a certified nurse midwife, or a certified registered nurse anesthetist. The paper, Understanding Medicare Part B “Incident to Billing, was developed by a work group that consisted of Sue Hill, Chris Rorick and Jan Colwell. “Incident to” refers to a Medicare billing mechanism, allowing services furnished in an outpatient setting to be provided by auxiliary personnel and billed under the provider's national provider identification (NPI) number. In some outpatient settings this may mean that a provider (physician or APRN) can develop the plan of care and a non APRN can provide the care and bill under the providers NPI number. This might in some cases allow a non APR/WOC nurse to bill in the outpatient setting.
One billing opportunity not covered in either sheet is the use of a facility fee. This a fee that can be charged to cover the use of the outpatient facility, the nursing services utilized during that visit, surgical dressing, drugs including biologicals, splints and casts and administrative, record keeping and housekeeping items and services. The fees take into account the operating and overhead costs related to the building, service provided by the clinical staff, supplies and equipment. WOC nurses who are not APRNs may use the facility charge.
The two papers developed by the Reimbursement Task Force should serve as a starting point for our members to begin to understand the issues involved in seeking reimbursement for wound, ostomy and continence services. The fact sheets are the best information that was available at the time of development and are not meant to be a final official document; rather they will be reference sheets to begin to seek out reimbursement opportunities in various care settings. Both sheets contain numerous citations as well as further reading on the subjects.