Tip: Ensure appropriate attribution for APPs

Many organizations continue to struggle with appropriately attributing care provided by advanced practice professionals (APP), especially when there are specific supervision requirements in place that must be met before the patient encounter can be closed. Coding such encounters appropriately for billing purposes can be a significant challenge, particularly when resources and/or technological capabilities are limited. Organizations must find a way to resolve these issues for many reasons, including patient safety, performance improvement endeavors, risk management, and regulatory and accreditation requirements.

Until organizations are capable of accurately capturing the activity of APPs, a temporary solution is to request that APPs provide a log of patients seen. This may be created manually by the APP or may be produced by generating a copy of the APP’s billing records.

Another option is to attribute the outcome data to both the physician and the APP, as appropriate. For example, attribution of a post-operative infection would be to both the surgeon and the physician assistant, unless the record documents a clear break of technique or complication caused by one of the individuals. Similarly, a readmission for congestive heart failure would be attributed to both the internist and the nurse practitioner who cared for the patient while in the hospital. Lastly, the lengthy hospital course for an uneventful vaginal delivery would be attributed to the obstetrician as well as the midwife who cared for the patient.

Additionally, whenever a peer review committee has evaluated a case and determined that the care provided deviated from expected standards, the committee should attribute the case separately to each member of the care team as appropriate. For example, the committee would need to identify whether specific concerns regarding the care, treatment, or services that did not meet expectations should be attributed to the APP (or other members of the care team) rather than solely to the attending physician.

Another reason to accurately attribute care provided by APPs is similar to the circumstances of a resident or fellow. In most states, even if an APP is allowed to bill for certain services, physicians are still required to supervise. The organization should not only be ensuring that patient care is attributed to the correct APP for billing and quality purposes, but it should also be monitoring whether the appropriate supervision (as required by the state board and/or organization’s policy) is being provided. Therefore, when a complication is identified and attributed to the APP, it is also important to determine if the complication resulted from the lack of appropriate supervision. If so, then the complication and supervision concerns would also be attributed to the responsible attending.

Source: The Medical Staff’s Guide to Overcoming Competence Assessment Challenges