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Abstract #153289

Susan C. Vonderheid, PhD, RN, Maternal Child Nursing, University of Illinois at Chicago, 845 S. Damen Avenue, Room 846, Chicago, IL 60612, 312-996-7982, vonde@uic.edu, Joanne M. Pohl, PhD, APRN, BC, FAAN, School of Nursing, University of Michigan, 400 North Ingalls Street, Room 1343, Ann Arbor, MI 48109-0482, Clare Tanner, PhD, Center for Collaborative Research in Health Outcomes and Policy, Michigan Public Health Institute, 2440 Woodlake Circle, Suite 100, Okemos, MI 48864, and Jamesetta A. Newland, PhD, APRN, BC, Lienhard School of Nursing, Pace University, 41 Park Row, Room 313, New York, NY 10038.

Background: Nurse managed centers (NMCs) play an important role as safety net providers in the U.S., often caring for vulnerable populations. Yet, many NMCs struggle to succeed financially. Assessment of Current Procedural Terminology (CPT) coding patterns is a key strategy to support long-term sustainability. Purpose: To compare coding patterns of nurse practitioners (NPs) in NMCs delivering primary care with the Centers for Medicare and Medicaid Services' (CMS) data of NPs and family physicians (FPs). Framework: CMS guidelines use CPT codes to document services provided and to determine reimbursement for professional healthcare services. For office visit codes, higher code numbers indicate higher levels (1 through 5) of service intensity (and reimbursement). Design: A descriptive, retrospective study to develop a national NMC database and to identify NMC benchmarks. Subjects: 13 centers reported CPT data. Centers represented diverse locations, populations, and funding sources. Method: A standardized survey was distributed via email to 122 NMCs listed in a national directory. Of 42 NMCs that responded, 30 participated and completed surveys. NMCs were asked to submit a list of all CPT codes, other financial data, and center characteristics for year 2004/2005. Frequency distributions and ratios of CPT codes were compared across NMCs and with national data, focusing on Evaluation and Management (E&M) codes for ambulatory care visits. Interviews were conducted with center representatives to more fully understand the (mis)match between findings and a center's population served. Results: Among NMCs, the distribution of new patient visit codes showed markedly high utilization of codes representing less intensive services. For established patient visit codes, the distribution was closer to a normal curve, yet continued to show higher utilization of codes representing less intensive services. Compared to CMS data, while NMC data were more similar to NP data, NMC data consistently showed higher use of less intensive services than either NPs or FPs in non NMC sites. Examination of distributions of many individual NMCs found little to no use of higher intensity services suggesting undercoding. Discussion: Reasons for coding variations among national data and among centers are described. Implications for education, practice, research, and policy are discussed.

Learning Objectives:

• Describe the reasons that health care providers, specifically providers at nurse-managed centers, need to accurately document services provided.
• Describe similarities and differences among coding patterns of providers at nurse-managed centers with NP and FP data from the Centers for Medicare and Medicaid Services’ database.
• Describe implications of coding variations across centers for education, practice, research and policy.

Keywords: Health Care Delivery, Community Health Centers

Presenting author's disclosure statement:

Any relevant financial relationships? No
Any institutionally-contracted trials related to this submission?

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.