How are you using/training your APPs in ordnance with CMS and ACR?

[d32]

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Outside of consults and follow ups? OTV? supervision of machines? SBRT?

 

[BobbyHeenan]

Only follow ups and inpatient consults (on inpatients the APP may see the patient and order some work up before the doc sees the patient) . We also have APP's do notes for tx summaries. They see patients under treatment for management if a new issue arises that is not on the OTV day.

It is our understanding that you cannot bill OTV's if the patient is only seeing the APP, so they don't see weekly visits routinely unless they see the patient first, then the MD comes in room later.

We occasionally use our NP to "babysit" clinic if a doc is not on site (doc remotely reviewing films), but will not do an SBRT with an APP. CT sims, verification sims/new starts, HDR, SBRT is all MD-only.

 

[HolySmokes]

Only follow ups and inpatient consults (on inpatients the APP may see the patient and order some work up before the doc sees the patient) . We also have APP's do notes for tx summaries. They see patients under treatment for management if a new issue arises that is not on the OTV day.

It is our understanding that you cannot bill OTV's if the patient is only seeing the APP, so they don't see weekly visits routinely unless they see the patient first, then the MD comes in room later.

We occasionally use our NP to "babysit" clinic if a doc is not on site (doc remotely reviewing films), but will not do an SBRT with an APP. CT sims, verification sims/new starts, HDR, SBRT is all MD-only.

This is our exact set up.

 

[TheWallnerus]

It is our understanding that you cannot bill OTV's if the patient is only seeing the APP, so they don't see weekly visits routinely unless they see the patient first, then the MD comes in room later.

PAs are billing Medicare for 77427 and getting paid (at the usual 85% rate) according to publicly available data. I am not opining on the rightness or wrongness of this!

 

[BobbyHeenan]

PAs are billing Medicare for 77427 and getting paid (at the usual 85% rate) according to publicly available data. I am not opining on the rightness or wrongness of this!

I’m sorry to hear that.

That’s a really important part of my job and think it’s a dis service to patients to farm that out.

It’s also not some rare thing where if I see a toxicity more severe than I’d expect and or some borderline call on a target volume or plan I may adjust my plan based on toxicity.

Just last week I re planned a lung mid treatment to be colder on the esophagus due to esophagitis I was having a hard time managing in a very frail patient. So pushed it harder with dosimetry and made adjustments and judgement calls … calls a rad onc can make not an NP.

 

[kimplera]

I’m sorry to hear that.

That’s a really important part of my job and think it’s a dis service to patients to farm that out.

It’s also not some rare thing where if I see a toxicity more severe than I’d expect and or some borderline call on a target volume or plan I may adjust my plan based on toxicity.

Just last week I re planned a lung mid treatment to be colder on the esophagus due to esophagitis I was having a hard time managing in a very frail patient. So pushed it harder with dosimetry and made adjustments and judgement calls … calls a rad onc can make not an NP.

we are also using them in the post-RT setting - my H&N who struggle to the end of treatment see the APP 2 weeks out. Considering moving all visits to 90 days to the APP (at our facility the metric for APPs is appointment slots booked so within the global window is a great use). we are encouraged to transition all f/u to APPs, but honestly i am struggling with that cause i really like seeing most of the patients

 

[BobbyHeenan]

we are also using them in the post-RT setting - my H&N who struggle to the end of treatment see the APP 2 weeks out. Considering moving all visits to 90 days to the APP (at our facility the metric for APPs is appointment slots booked so within the global window is a great use). we are encouraged to transition all f/u to APPs, but honestly i am struggling with that cause i really like seeing most of the patients

I'm with you. My partner(s) use the APP's much more than I do.

I have control issues and just enjoy seeing them, really want to know what is up.

But yes, that's a great use of APP. I end up seeing my head/necks weekly with IVF's often first few weeks after treatment and would be agood slot for an NP to be helping them with acute post tx issues.

 

[yesmaster]

I don’t use or train APP’s.

 

[metallica81788]

This is great info so please keep it coming

An APP is probably my only route to a 4 day work week and my organization seems surprisingly supportive right now

 

[BobbyHeenan]

This is great info so please keep it coming

An APP is probably my only route to a 4 day work week and my organization seems surprisingly supportive right now

Because they're probably thinking it will be like med onc where they bill above what they get paid. They aren't realizing that you can't bill anything in the 90-day window after treatment and/or symptom management during XRT isn't billable for them and that can be a big chunk of their work. Managing chemo side effects doesn't have these bundling periods.

But don't let them in on it and go for it.

One thing we are exploring is having the NP be involved as a hybrid NP/navigator for the radiopharm program. If the hospital won't give us a cut of that massive $ they make off radiopharm (and pro codes /RVU's are ABYSMAL), then at least they can provide an NP to help monitor/coordinate and assist with symptom management.

 

[firewicket]

OTVs are certainly a NO NO for NPs according to CMS...doesnt matter if insurance is reimbursing it. It is illegal per CMS (you actually have to read the laws people).
I use NP for inpatient consult screen with seeing the patient at least 24 hours after the NP.
I also use them extensively fir FUs at 85% reimbursement.

MY question, and LIKELY THE MOST IMPORTANT GOING FORWARD.

Can an NP be used for direct supervision under the APEX and ACR accreditation process for hospital based practices.

CMS has made it clear that GENERAL supervision is perfectly fine. A doc, and an RO NP do NOT need to be present when the machine is on any ore (this is not a discussion regarding ASTROs politically motivated interpretation). CMS is clear that it is GENERAL supervision. CMS is all that matter.

Where that is going to get veeeeery complicated it the new ROCR legislation.

The current bill states that APEX OR ACR accreditation is NEEDED to receive reimbursement of ROCR (which is Medicare, and thus CMS).
APEX and ACR require direct supervision...

Likewise the ROCR bill is going to mandate direct supervision AGAIN! WE will lose our general supervision...not having to babysit the machine.

Can an NP be used for direct supervision under APEX or ACR?

 

[Bequerel]

Is the ROCR actually going to happen? I’ve just put my head in the sand and have assumed that, like every other big ASTRO idea, this will just disappear

 

[firewicket]

It will probably pass yes.

 

[HolySmokes]

It will probably pass yes.

 

[TheWallnerus]

OTVs are certainly a NO NO for NPs according to CMS...doesnt matter if insurance is reimbursing it. It is illegal per CMS (you actually have to read the laws people).

As I said Medicare is reimbursing it (not insurance per se). Where is the law that says Medicare is breaking the law by reimbursing for it.

 

[alwaysbeIMRTing]

Where that is going to get veeeeery complicated it the new ROCR legislation.

The current bill states that APEX OR ACR accreditation is NEEDED to receive reimbursement of ROCR (which is Medicare, and thus CMS).
APEX and ACR require direct supervision...

No way this holds up to legal scrutiny. Doctors are forced to pay a non-governmental accrediting agency in order to get paid by CMS? Seriously? What are these people smoking to think that not only can we pigeon-hole ourselves into some special payment system while every other medical specialty continues to bill under the current system of CPT codes, but also that the authors who came up with this dumpster fire also want to mandate accreditation by their own organization so they can bully every rad onc in the country as to how they can deliver radiation. It's a complete and obvious anti-competitive racket and I would be baffled if it's not completely laughed out of the room in DC.

 

[BobbyHeenan]

Is the ROCR actually going to happen? I’ve just put my head in the sand and have assumed that, like every other big ASTRO idea, this will just disappear

I've tried to study/read and back of envelope model but it's not worth the time.

Someone notify me when it's up for a vote.

I do agree with sentiments that if someone wanted to fight it (re: has enough $ to pay legal fees), the third party accreditation angle may not meet legal anti-trust standards.

 

[medgator]

It will probably pass yes.

No it won't. It won't even get brought up I bet. ASTRO is inept and impotent when dealing with CMS and the government IMO

 

[alwaysbeIMRTing]

No it won't. It won't even get brought up I bet. ASTRO is inept and impotent when dealing with CMS and the government IMO

Exactly. ASTRO is claiming this will stabilize payments for rad onc in the future to protect against further CMS cuts. That is literally how they are trying to sell it to us in public. In the current environment of selective budget cuts to futilely try and protect spending elsewhere (either entitlements or defense, pick your poison), does anybody think that's really going to fly? And I don't care, because I don't believe that either the intent is to stabilize our payments or that it will. The intent is to burden community practices and further funnel care into large systems, which drives up the cost of care. They are lying. This is their M.O. over and over again.

 

[medgator]

View attachment 405006

Yup. ASTRO doesn't even have clout with the ruc and AMA.

Hard to take an organization seriously that was screaming at CMS to bring back direct supervision last year when ACR and the rest of the specialty organizations saw the light when that ship sailed in 2020.