Can a Nurse Practitioner Be the 'Attending Physician' in the Hospital Setting?

Carolyn Buppert, MSN, JD

Disclosures

August 26, 2015

Here is Medicare's definition of attending physicians:

Qualifications of the ordering/admitting practitioner: the order must be furnished by a physician or other practitioner ("ordering practitioner") who is: (a) licensed by the state to admit inpatients to hospitals, (b) granted privileges by the hospital to admit inpatients to that specific facility, and (c) knowledgeable about the patient's hospital course, medical plan of care, and current condition at the time of admission. The ordering practitioner makes the determination of medical necessity for inpatient care and renders the admission decision. The ordering practitioner is not required to write the order but must sign the order reflecting that he or she has made the decision to admit the patient for inpatient services. The ordering practitioner may be, but is not required to be, the physician who signs the certification. Please see section (B)(3) for a discussion of the requirements to be knowledgeable about the patient's hospital course. See section (A)(3) for the list of physicians authorized to certify a given case. The admission decision (order) may not be delegated to another individual who is not authorized by the state to admit patients, or has not been granted admitting privileges by the hospital's medical staff (42 CFR 412.3[b]). However, a medical resident, a physician assistant, nurse practitioner, or other non-physician practitioner may act as a proxy for the ordering practitioner provided they are authorized under state law to admit patients and the requirements outlined below are met.

Residents and non-physician practitioners authorized to make initial admission decisions: certain non-physician practitioners and residents working within their residency program are authorized by the state in which the hospital is located to admit inpatients, and are allowed by hospital by-laws or policies to do the same. The ordering practitioner may allow these individuals to write inpatient admission orders on his or her behalf, if the ordering practitioner approves and accepts responsibility for the admission decision by countersigning the order prior to discharge. (Please see (A)(2) for guidance regarding the definition of discharge time and (B)(3) for more guidance regarding knowledge of a patient’s hospital course). In countersigning the order, the ordering practitioner approves and accepts responsibility for the admission decision. This process may also be used for physicians (such as emergency department physicians) who do not have admitting privileges but are authorized by the hospital to issue temporary or 'bridge' inpatient admission orders.

...Knowledge of the patient's hospital course: Medicare considers only the following practitioners to have sufficient knowledge about the beneficiary's hospital course, medical plan of care, and current condition to serve as the ordering practitioner: the admitting physician of record ('attending') or a physician on call for him or her, primary or covering hospitalists caring for the patient in the hospital, the beneficiary's primary care practitioner or a physician on call for the primary care practitioner, a surgeon responsible for a major surgical procedure on the beneficiary or a surgeon on call for him or her, emergency or clinic practitioners caring for the beneficiary at the point of inpatient admission, and other practitioners qualified to admit inpatients and actively treating the beneficiary at the point of the inpatient admission decision. Although a utilization review committee physician may sign the certification on behalf of a non‐physician admitting practitioner, a practitioner functioning in that role does not have direct responsibility for the care of the patient and is therefore not considered to be sufficiently knowledgeable to order the inpatient admission. The order must be written by one of the above practitioners directly involved with the care of the beneficiary, and a utilization committee physician may only write the order to admit if he or she is not acting in a utilization review capacity and fulfills one of the direct patient care roles, such as the attending physician. Utilization review may not be conducted by any individual who was professionally involved in the care of the patient whose case is being reviewed (42 CFR 482.30(d)(3)).[3]

To summarize, a nurse practitioner may perform the admission history and physical, and bill for that work, using the Current Procedural Terminology (CPT) code for an "initial hospital visit." Even so, the nurse practitioner is not considered to be the "attending physician," and the patient must have an attending physician. If the attending physician performs an admission history and physical, then he or she bills the appropriate CPT code and appends the modifier "-AI." More than one clinician may bill an initial hospital visit, as long as the clinicians are not in the same specialty.

So, although a nurse practitioner cannot be the attending physician of record for hospitalized patients, a nurse practitioner may perform and bill the admission history and physical, an initial hospital visit, and subsequent hospital visits. A physician must be listed as attending physician, and that individual must approve the admission and vouch for the medical necessity of the admission.

Related Resource

MLN Matters #6740 (2010) Revisions to Consultation Services Payment Policy

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