Volume 14, Issue 2, August 2003   
Coordinator's Corner
SIG Members Take Active Part in Congress and Other Activities

Diane Cope, PhD, ARNP-BC, AOCN®
Fort Meyers, FL

I’d like to take this opportunity to introduce myself as I assume the role of SIG coordinator and also to update you on several SIG accomplishments and activities. I am a nurse practitioner (NP) at Florida Cancer Specialists, a very large hematology and oncology practice on the western coast of Florida. Prior to becoming an NP, I taught graduate and undergraduate nursing. I have been involved actively with the NP SIG for the past four years as the newsletter editor and coordinator-elect.

Our SIG was very well represented at the ONS 28th Annual Congress this year. For the second year, Kathleen Murphy-Ende, PhD, NP, AOCN®, was a member of the Congress Team. Instructional or podium sessions were given by SIG members Terri Armstrong, MS, APRN-BC, Christy Dolbey, RN, MSN, NP, AOCN®, Wendy Smith, RN, MSN, ACNP, AOCN®, Marianne Davies, RN, MSN, APRN, OCN®, ACNP, Karen Martin, RN, MSN, OCN®, ACNP, Janet VanCleave, MSN, ACNP-CS, AOCN®, Wendy Vogel, MSN, FNP, AOCN®, and me. Mary Pat Lynch, CRNP, MSN, AOCN®, coordinated a very informative special symposium on reimbursement issues presented by expert Carolyn Buppert, CRNP, JD. Great job, everyone!

The ONS Nurse Practitioner SIG Newsletter
is underwritten through a grant from Amgen, Inc.


Special Interest Group Newsletter  August 2003

Coordinator's Corner
SIG Members Take Active Part in Congress and Other Activities

Diane Cope, PhD, ARNP-BC, AOCN®
Fort Meyers, FL

I’d like to take this opportunity to introduce myself as I assume the role of SIG coordinator and also to update you on several SIG accomplishments and activities. I am a nurse practitioner (NP) at Florida Cancer Specialists, a very large hematology and oncology practice on the western coast of Florida. Prior to becoming an NP, I taught graduate and undergraduate nursing. I have been involved actively with the NP SIG for the past four years as the newsletter editor and coordinator-elect.

Our SIG was very well represented at the ONS 28th Annual Congress this year. For the second year, Kathleen Murphy-Ende, PhD, NP, AOCN®, was a member of the Congress Team. Instructional or podium sessions were given by SIG members Terri Armstrong, MS, APRN-BC, Christy Dolbey, RN, MSN, NP, AOCN®, Wendy Smith, RN, MSN, ACNP, AOCN®, Marianne Davies, RN, MSN, APRN, OCN®, ACNP, Karen Martin, RN, MSN, OCN®, ACNP, Janet VanCleave, MSN, ACNP-CS, AOCN®, Wendy Vogel, MSN, FNP, AOCN®, and me. Mary Pat Lynch, CRNP, MSN, AOCN®, coordinated a very informative special symposium on reimbursement issues presented by expert Carolyn Buppert, CRNP, JD. Great job, everyone!

The projects and activities of our SIG continue to grow and flourish. Special recognition should be given to all of the SIG leaders, past and present, who have done so much for the SIG. Terri Armstrong, ex officio, has done an outstanding job for the past two years as coordinator and as the previous newsletter editor. Mary Pat Lynch, the coordinator preceding Terri, continues to remain very active and supportive by contributing to the SIG with educational programs and represented the SIG as team leader for the 2002 Advanced Practice Nurse retreat. The chairs of the work groups have been instrumental in developing many projects to support NP SIG members. These individuals include Barb Biedryski, RN, MSN, AOCN®, CRNP, archives; Wendy Vogel, legislative issues; Christy Dolbey and Marianne Davies, Mentor/Mentee Program; Marybeth Singer, RN, MS, CS, AOCN®, Web page administrator; and Christie Hancock, APN, MSN, RN, CS, OCN®, and Janet VanCleave, newsletter. Thank you all for your ongoing efforts and outstanding work. If you would like to volunteer for one of these work groups, please contact me (see SIG Officers page for all contact information). Lastly, please let me know if you have any directions, problems, concerns, or suggestions. I look forward to working with all of you during the next two years.
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Special Interest Group Newsletter  August 2003

Reimbursement and Collaborative Practice: Nurse Practitioner SIG-Sponsored Activities at Congress 2003

Mary Pat Lynch, CRNP, MSN, AOCN®
Haveford, PA

Nurse Practitioner (NP) SIG members who attended the ONS 28th Annual Congress in Denver, CO, this May were fortunate to hear from Carolyn Buppert, CRNP, JD, at two sessions sponsored by the NP SIG. Buppert is a nationally known expert on NP reimbursement and collaborative practice. She spoke at a special evening symposium cosponsored by the NP and Clinical Nurse Specialist SIGs and the 2001 Advanced Practice Nurse (APN) Retreat Team. Approximately 100 APNs attended the program. The following day, Buppert was a speaker at the APN issues discussion session. She spoke about reimbursement and collaborative practice, along with Regina Cunningham, RN, MSN, who discussed APN outcomes.

The following topics were among those covered in her presentations.

  • APNs may provide physician or nursing services.
  • Reimbursement for physician and nursing services are under separate systems.
  • APN authority to bill comes from federal and state law.
  • Legal authority or “scope of practice” comes from state law and varies by state.
  • NPs need a scope of practice that bestows the authority to perform and bill for physician services.
  • “Incident to” billing is the most misunderstood concept in billing.
  • The authority for NPs to bill Medicare and to bill incident to comes from the U.S. Congress in the Balanced Budget Act of 1997.
  • Mistakes with fraud implications include not following
    • Incident to rules
    • Rules regarding bundling of charges
    • Rules on coding.
  • Resources for reimbursement include
    • Local Medicare carrier provider seminars
    • The Centers for Medicare and Medicaid Services' Web site at www.cms.gov
    • Current procedural terminology
    • “Safe, Smart Billing and Coding for Evaluation and Management,” an educational module on CD, available on Buppert’s Web site at www.buppert.com.
We hope to have the slides from Buppert’s evening symposium talk available on the NP SIG Virtual Community in the near future so that we can share this valuable resource with those who were unable to attend the program. Buppert’s Web site contains a wealth of information and resources for NPs. The NP SIG is working on developing submissions for future meetings on the topics of reimbursement and collaborative practice because they are significant to the practice of oncology NPs.
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Special Interest Group Newsletter  August 2003

Smallpox Virus Can Be a Bioterrorism Agent

Melissa A. Burrow, RNP, MSN

Christie Hancock, APN, MSN, RN, CS, OCN®
Jonesboro, AR

The events of September 11, 2001, as well as our current opposition against Iraq, have significantly changed our views on bioterrorism and the potential threat to the United States. Bioterrorism can be described as the use or potential use of biologic agents to intimidate a single person, group of people, or complete population. On a small scale, our country already has been threatened with the bioterrorism agent anthrax. Now, a heightened international concern exists regarding the potential use of the smallpox (variola) virus as a biologic weapon. The use of the smallpox virus as a bioterrorism agent would have substantial public health consequences. As healthcare practitioners, we need to be knowledgeable regarding signs and symptoms of the smallpox virus, the vaccine for smallpox, and their effects on the health of our patients.

History of the Smallpox Virus
Smallpox first was used as a biologic weapon in North America during the French and Indian War from 1754–1767 by the British forces. The British forces gave the Native Americans blankets that had been used by patients with smallpox with the intent of causing outbreaks. Massive epidemics occurred, killing more than 50% of the affected tribes (Henderson et al., 1999). In 1796, Edward Jenner first used the vacinna virus (more commonly known as cowpox) as prophylaxis against smallpox. This was used as a vaccine for almost 200 years (Diven, 2001). From 1967–1977, the World Health Organization (WHO) began a global campaign that resulted in successful eradication of smallpox. On May 8, 1980, WHO declared that the world was free from smallpox (Diven). The last detected case of smallpox in the United States occurred in 1949 (Centers for Disease Control and Prevention [CDC], 2001). The variola virus has been eliminated with the exception of laboratory stockpiles.

Overview of the Smallpox Virus
The smallpox virus is a member of the genus orthopoxvirus. The orthopoxviruses are among the largest and most complex of all viruses (Diven, 2001). The smallpox virus has two subtypes: variola major and variola minor. Variola major consists of four categories: ordinary, modified, flat, and hemorrhagic. Ordinary variola major is the most frequent type of the smallpox virus, accounting for 90% of cases (CDC, 2001). Smallpox is transmitted by direct face-to-face contact or through direct contact with infected body fluids or contaminated objects (such as bedding or clothing). Once a person is exposed to the smallpox virus, the disease progresses through several phases.

The first phase, known as the incubation phase, can last 7–17 days. People do not have any symptoms during this phase and are not contagious. The second phase, or prodrome phase, can last two to four days. During this time, the first symptoms of smallpox appear, including fever, malaise, headaches, arthralgias, and vomiting. The third phase, or eruptive phase, lasts about 14 days. People are most contagious during this phase. An erythematous, maculopapular rash appears, usually first on the tongue and mouth and then spreading to the throat. This rash progresses to the skin, starting on the face and spreading to the upper and lower extremities. As the rash spreads throughout the body, it begins to change from papules to vesicles to pustules. By the end of the second week, most of the pustules have begun to scab over. People are contagious until all of the scabs have resolved.

Diagnosis and Care of Smallpox
If a diagnosis of smallpox is considered, the person and all those in contact with the person should be isolated immediately and CDC should be contacted. A laboratory confirmation can be obtained from silver impregnation or fluorescent antibody staining of smears taken from the skin lesions. A negative smear does not exclude the disease. Smallpox also may be diagnosed by drawing a titer. A fourfold rise in antibody titer is considered positive for the virus (Diven, 2001). Differential diagnosis for smallpox is varicella or chicken pox.

No treatment for smallpox exists. Primary prevention by vaccination is the best treatment in cases of a potential threat of an outbreak or epidemic. Supportive care with pain medications and prevention of bacterial infections is necessary.

Eligibility for the Smallpox Vaccine
The U.S. government is prepared to immunize the American public in the event of a smallpox outbreak. The smallpox vaccine is the best protection available once exposure to the smallpox virus occurs. Certain at-risk populations may experience reactions to the vaccine ranging from serious to life-threatening. However, any individual who has been exposed directly to smallpox, regardless of health status, would be offered vaccination because the potential harm secondary to smallpox outweighs the risk associated with the vaccine (CDC, 2001).

Individuals who have been diagnosed with or who are experiencing eczema, atopic dermatitis, burns, chicken pox, shingles, impetigo, herpes, severe acne, psoriasis, a weakened immune system, or pregnancy should not get the smallpox vaccine unless they have been exposed to the smallpox virus (CDC, 2001). Also, anyone who is allergic to the vaccine or any of the ingredients, younger than 12 months, breast feeding, or experiencing a moderate or severe short-term illness should avoid vaccination. However, the general public must be aware that vaccination is necessary in the event of direct exposure to the smallpox virus regardless of health status.

Reactions: Mild Versus Life-Threatening
The smallpox vaccine is safe for the majority of people. Normal, mild reactions may include tenderness and erythema in the vaccinated arm, regional adenopathy, and low-grade fever. More serious reactions (that require medical attention) may include a vaccinia rash or outbreak of sores limited to one area, widespread vaccinia rash, or toxic or allergic rash that may take various forms including erythema multiforme. Life-threatening reactions rarely occur (between 14–52 people per one million) but require immediate medical attention. Eczema vaccinatum (serious skin rashes caused by widespread infection of the skin), progressive vaccinia (infection of the skin with tissue destruction), and postvaccinal encephalitis (inflammation of the brain) are examples of life-threatening reactions to the smallpox vaccine (CDC, 2001). Death may occur in one to two people out of every one million people vaccinated (CDC).


Smallpox vaccination provides significant immunity for three to five years and decreases thereafter. Revaccination results in prolonged immunity. The smallpox vaccine prevents smallpox infection in 95% of individuals vaccinated and also is effective in either preventing or minimizing infection when given within a few days of exposure (CDC, 2001).

The use of bioterrorism agents has become an increasingly realistic threat in today’s society. Healthcare practitioners must assume a leadership role in the education and preparation of the public to help ensure the safety of our nation.

Centers for Disease Control and Prevention. (2001). Smallpox fact sheet. Atlanta, GA: Author.

Diven, D.G. (2001). An overview of poxviruses. Journal of the American Academy of Dermatology, 44, 1–14.

Henderson, D.A., Inglesby, T.V., Bartlett, J.G., Ascher, M.S., Eitzen, E., Jahrling, P.B., et al. (1999). Smallpox as a biological weapon. JAMA, 281, 1–43.

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Special Interest Group Newsletter  August 2003

Drug Update
Voriconazole: Antifungal Treatment for Aspergillus

Christie Hancock, APN, MSN, RN, CS, OCN®
Jonesboro, AR

Aspergillus is a common fungus that can yield serious infections in people with cancer undergoing immunosuppressive therapy or people with advanced HIV. The fungus most commonly enters the host via the upper airway, typically causing pneumonia or a sinus infection. Aspergillus is characterized by blood vessel invasion, which can lead to thrombosis and infarction of pulmonary arteries and vessels (Ellerhorst-Ryan, 1993). An aspergillus infection can be difficult to diagnose and often requires aggressive treatment before a diagnosis is confirmed. Without aggressive treatment, aspergillus almost always is fatal.

In May 2002, the U.S. Food and Drug Administration granted approval for Vfend® (voriconazole, Pfizer Inc., New York, NY) for the treatment of fungal infections. Vfend is indicated for primary treatment of acute invasive aspergillus and salvage therapy for rare but serious fungal infections caused by the pathogens scedosporium apiospermum and fusarium. Vfend is a triazole antifungal agent that works principally by inhibiting the cytochrome P450 mediated 14 alpha-lanosterol demethylation, which is an essential step in fungal biosyntheses (Pfizer Inc., 2002).

Clinical Trials
The efficacy of Vfend as a primary therapy for invasive aspergillus was demonstrated in a randomized unblinded trial. The trial included subjects with solid organ transplant, solid tumors, and AIDS. Voriconazole was compared with amphotericin B for primary therapy of invasive aspergillus. Patients received IV voriconazole followed by 200 mg orally twice daily or IV amphotericin B deoxycholate. A total of 144 patients in the voriconazole group and 133 patients in the amphotericin group with definite or probable aspergillosis received at least one dose of treatment. At week 12, successful outcomes occurred in 52.8% of the patients in the voriconazole group and 31.6% in the amphotericin B group. A successful outcome was defined as complete or partial resolution of all symptoms, signs, and radiographic and bronchoscopic abnormalities present at baseline. Patients treated with Vfend had significantly fewer severe drug-related adverse effects, but treatment visual disturbances were common (Herbrecht et al., 2002).

Dosage and Administration
The recommended dosage of Vfend tablets for patients who weigh more than 40 kg is 200 mg every 12 hours. Patients who weigh less than 40 kg should receive a dosage of 100 mg every 12 hours. IV Vfend has a loading dose of 6 mg/kg every 12 hours for two doses followed by a maintenance dose of 4 mg/kg IV every 12 hours. Vfend tablets should be taken at least one hour prior to or one hour following a meal. Vfend IV for injection requires a reconstitution to 10 mg/ml and subsequent dilution to 5 mg/ml or less prior to administration as an infusion at a maximum rate of 3 mg/kg per hour over one to two hours.

Side-Effect Profile
The most frequently reported adverse events in the therapeutic trials of Vfend were visual disturbances (28%), vomiting (11%), nausea (7.1%), rash (6.6%), fever (3.6%), headache (3.6%), abdominal pain (2.6%), and diarrhea (1.5%). Voriconazole visual disturbances are common. In clinical trials, approximately 28% of patients experienced altered or enhanced visual perception, blurred vision, color vision change, or photophobia. The visual disturbances generally were mild and rarely resulted in discontinuation. The visual disturbances may be related to higher plasma concentrations or higher dosages (Herbrecht et al., 2002). Patients should be advised not to drive or operate machinery while they are receiving Vfend therapy because of the visual changes that can occur.


The number of patients at risk for infection is increasing because more patients are undergoing bone marrow transplants, solid organ transplants, and aggressive chemotherapy for cancer. Vfend shows successful efficacy and survival benefits for the treatment of invasive aspergillus and will provide healthcare practitioners with an additional tool in battling this deadly fungus.

Ellerhorst-Ryan, J.M. (1993). Infection. In S.L. Groenwald, M.H. Frogge, M. Goodman, & C.H. Yarbro (Eds.), Cancer nursing: Principles and practice (3rd ed., pp. 557–574). Boston: Jones and Bartlett.

Herbrecht, R., Denning, D.W., Patterson, T.F., Bennett, J.E., Greene, R.E., Oestmann, J.W., et al. (2002). Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. New England Journal of Medicine, 347, 408–415.

Pfizer Inc. (2002). Vfend® (voriconazole) product information. New York: Author.

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Special Interest Group Newsletter  August 2003

Reimbursement Rigors: An Overview of the Process

Wendy Vogel, MSN, FNP, AOCN®
Bristol, TN

“Rigors” is defined as an abrupt attack of shivering and sensation of coldness accompanied by a rapid rise in body temperature and may be followed by a feeling of heat with copious sweating. This is the way many of us feel when we are asked about reimbursement issues! However, reimbursement is critical to the survival of nurse practitioners (NPs). We need to be experts, yet most of us shy away from this part of our practice.

Playing by the Rules
Third party payors who may reimburse NP services can fall into several categories. These include Medicare, Medicaid, commercial indemnity insurers, commercial managed care organizations, and businesses or schools that want health services for employees or students. Each of these groups has a different set of rules for NP reimbursement.

Medicare will reimburse NPs if they meet certain qualifications (state license and national certification) and have a Medicare provider number. As of January 1, 2003, any NP applying for a Medicare provider number for the first time must have a master’s degree from an NP program. The practice or facility must accept Medicare’s payment, which is 85% of the physician fee schedule rate for bills submitted under the NP’s provider number. The services provided by the NP must be performed in collaboration with a physician and within the state law scope of practice.

All NPs must obtain a Medicare provider number. NPs may acquire an application by calling the local carrier or visiting www.cms.hhs.gov/providers/enrollment on the Centers for Medicare and Medicaid Services Web site. The name and telephone number of an NP’s local carrier can be found on the Internet at www.cms.hhs.gov/providers/enrollment/contacts. A UPIN (unique physician identification number) will be given with the provider number to be used when ordering services or durable medical goods.

No restrictions are imposed on what NPs can bill. The only criteria are that the service must be (a) a physician service and (b) allowed under the state scope of nursing practice for advanced practice nurses. NPs may bill any level evaluation and management (E & M) code. NPs may perform and bill for consultations if the state scope of practice allows. NPs also may bill for services provided in the hospital (unless employed by a hospital and the NPs’ salaries are part of the hospital’s Medicare cost report). NPs may bill for physician services provided in a nursing home or for home visits.

Many questions come up in the discussion of “incident to” billing. This is billing an NP’s service under the physician’s provider number and receiving 100% reimbursement, instead of the standard 85% of the physician’s fee schedule. However, the rules for incident to billing are rigid and restrictive, as noted in the following.

  1. Services must be under the physician’s direct personal supervision. This means that the physician must be present in the same office suite and immediately available. He cannot be reachable by pager or phone or working in another office suite.
  2. The physician must perform the initial service and “subsequent services at a frequency that reflects his or her active participation in the management of the course of treatment” (Centers for Medicare and Medicaid Services, 2001, section 2050.2) This means that the NP cannot see a new patient or an old patient with a new problem. The physician also must see the patient every certain number of visits. The sticky part is that your carrier may define how frequent. For instance, the carrier in Northeast Tennessee, Cigna Medicare, defines that as every third visit.
  3. The NP may bill for services of a non-NP (RN, medical assistant) under the NP’s provider number if the rules for incident to billing are met. This means you may bill for an electrocardiogram or chemotherapy charges if your office assistant actually performs it. The services will be reimbursed at 100%.
  4. Incident to billing is not allowed for hospital charges.
  5. The NP must be employed by the physician.
It probably is better not to bill incident to the physician for NP services. The 15% difference in reimbursement usually will not make up for the difficulty in scheduling and documentation for these patients. Do not assume that the physician’s signature will suffice to assure Medicare of the physician’s “readily available presence.” You must have adequate documentation of the physician’s presence by other medical records, scheduling logs, etc.

NPs also may bill Medicaid. To obtain an application for a Medicaid provider number, call your state’s Medicaid agency, ask for provider relations, and request a provider application. Medicaid rules do not necessarily follow Medicare rules. Each state’s regulations regarding the billing of NP services vary. NPs with Medicaid provider numbers may bill Medicaid on a fee-for-service basis for covered physician services (if the patient is not enrolled in a managed care plan) and most states reimburse NPs at 100% of the physician’s fee. This may not be true for Medicaid recipients in managed care plans because each managed care plan’s policies on NP reimbursement can differ.

Private insurers may or may not require a provider number. Each insurer should be queried as to their requirements for NPs and their reimbursement rates. In some instances, private insurers require NPs to bill incident to the physician. Reimbursement for NPs will vary amonginsurers.

In managed care organizations, NPs must request an application for admission to the panel of providers. When membership is received, NPs are designated as primary care providers, credentialed, listed in the managed care organization directory, and qualified for reimbursement. Some managed care organizations may deny membership but allow NPs to provide services for enrolled patients of their collaborating physician. Others may not allow NP services at all.

Evaluation and Management Coding
NPs must be extremely skilled in the use of E & M codes used for billing Medicare and other insurances. Medical record documentation must meet the criteria for the E & M code billed. An E & M code has three components.

  1. History (including the chief complaint, history of present illness [HPI], review of systems [ROS], and past, family, and social history[PFS])
  2. Physical examination (includes four different levels based on extent of examination)
  3. Medical decision making (includes four levels based on complexity and time)
Although it is beyond the scope of this article to teach you all you need to know, I briefly will review some guidelines and then present some tips on reimbursement. Current recommendations are that NPs take a course in E & M coding at least once a year. Stay alert for revisions of the documentation guidelines that may be changing in the near future. Perform periodic audits comparing your coding and documentation. A helpful tool for your personal digital assistant is the program Stat E & M Coder™ (Austin Physician Productivity, LLC, Austin, TX). This can be downloaded for free from www.Statcoder.com.

The codes first are subdivided by the type of patient: new patient, consult, established patient, hospitalized, or emergency room visit. The components or elements required to meet a certain level of coding may differ according to the type of practice you have (general medicine versus obstetrics and gynecology versus ophthalmology). The general multisystem examination generally is used in oncology, and a discussion of its components follows.

The history component consists of HPI, ROS, and PFS. The depth of the history taking determines the level assigned: problem focused, expanded problem focused, detailed, or comprehensive. The number of elements inquired about during the history taking determines the code level. A nurse or medical assistant may take the history, but the NP must review and document it, making additional notes as needed.

The examination component consists of various elements of your physical examination. The more body areas you examine, the higher code you may bill (provided the history and decision making meet the higher code elements). For example, a comprehensive general multisystem examination would include head and neck, chest, abdomen, genitalia, groin, buttocks, back and spine, and extremities.

The medical decision-making component is often the hardest to quantify. The NP must decide how complex the decision making was for each patient visit. The number of diagnoses, if patients are acute or chronic or stable or unstable, if treatments are ordered, if diagnostic tests are ordered, etc., all must be considered.

These three components then are combined for the billing code. A certain number of elements in each component must be met to qualify for a particular code. The documentation must correspond to the code, showing that each required element was met.

The following are some helpful tips about billing.
  1. Level 1 visits (99211) are generally for nurse visits (blood pressure checks, immunizations, nurse assessments, etc.). NPs should bill 99212 or higher.
  2. Remember the bell curve. The majority of your visits most likely will be level 3 (99213) with a few level 2 and 4 and an occasional level 5. However, for a specialty service like oncology, a disproportionate number of level 4 visits may occur. If your bell curve of visits is not bell shaped, you may be set up for an audit.
  3. If you are billing for a relatively new procedure or treatment, keep a file of medical literature in case of denial of payment so you can appeal.
  4. Do not waive copayments. Medicare rules call for collection of a 20% copayment at time of service. If your practice doesn’t collect copayments, then Medicare can take that as indication that 80% reimbursement is adequate to cover medical expenses and will not raise reimbursement rates.
  5. Document specific diagnoses or symptoms. For example, do not use “rule out pulmonary embolus,” but use “shortness of breath, acute.” Document comorbidities and qualify these as acute, stable, improved, worsening, exacerbation, inadequately controlled, etc. This can justify the complexity of your medical decision making. Use five-digit ICD-9 codes because these often denote whether a condition is controlled or uncontrolled, thus impacting your decision making.
  6. Document initiation of and changes to treatment. Include any instructions or educational materials given to the patient. Documentation of the different treatment or management options that you considered also can justify the complexity of your decision making. Document noncompliance and risk factors (e.g., smoking, obesity).
  7. Document referrals, consultation, advice sought, or consultation from your collaborating physician. Document your request and perusal of old records, review of phone calls to the office, etc., and how this affected your level of decision making.
  8. Time can be a factor in billing. If coordination of care (counseling, answering questions, reviewing plan of care, reassurance, etc.) is more than 50% of the visit, you should document the time spent with the patient. With proper documentation, you may be able to bill a level higher.
What Are You Worth?
Want to ask for a raise? Trying to justify your salary request when interviewing for a new job? How do you know what you are worth? The following is an easy formula for calculating just that. NPs should know what they are bringing to their practice. Even if your practice doesn’t share this information with you (and they should!), you still can get a close calculation of your cost to the practice and your contribution to its financial goals.
  1. Know what your cost is.

    Salary + benefits + your share of overhead + compensation for physician consult = your cost to your employer.

    This is what you have to bring in for your employer to break even. Benefits may include insurance, malpractice, vacation, retirement, continuing education, Medicare and Social Security premiums, and worker’s comp. Your benefits coordinator should be able to tell you what percent of your salary your benefits are worth. This generally is around 26% of your salary. Oncology practices typically have a higher overhead than general practices.

  2. Know your average number of patients per day and average charges per visit.
    You can tally this yourself by keeping a record for two to three weeks and knowing what your practice charges per visit.

    Example: number of patients per day x 5 days per week x 48 weeks per year x average charge per visit = what you are billing for the practice. (But remember, what is billed and what is collected are two different numbers!)

  3. Know what your collection percentage rate is. If it is below 90%, you should be asking why.

    Total yearly billings x your collection percent rate = the total revenues you bring into the practice.

  4. Subtract your cost from your revenues. This is what profit you generate for your practice each year. Any APN who generates $30,000–$40,000 per year should be considered worthwhile.
Centers for Medicare and Medicaid Services. (2001). Coverage and limitations: Services and supplies. In Carriers manual: Part 3: Claims process (section 2050.1–2050.2). Baltimore, MD: Author.

American Medical Association. (2002). Physician’s current procedural terminology. Chicago: Author.

Buppert, C. (2000). The primary care provider’s guide to compensation and quality. Annapolis, MD: Aspen Publishers.

Buppert, C. (2002). Billing for nurse practitioner services: Guidelines for NPs, physicians, employers, and insurers. Medscape Nurses, 4(1). Retrieved July 1, 2003, from http://www.medscape.com/viewarticle/422935

MedLearn. (2002). Nurse practitioners’ guide to evaluation and management coding. St. Paul, MN: Author.

Online Resources for Reimbursement
American College of Nurse Practitioners
Centers for Medicare and Medicaid Services

Stat E & M Coder

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Special Interest Group Newsletter  August 2003

Connect to the Nurse Practitioner SIG Virtual Community

A great way to stay connected to the Nurse Practitioner (NP) SIG is to join the Virtual Community. It’s easy to do so by following these steps.

  • Log on to ONS Online.
  • Select “Virtual Communities” from the Quick Links menu.
  • Then, click on “ONS Special Interest Groups Virtual Community” from the Networking Groups menu shown.
  • Now, select “Find a SIG.”
  • Locate and click on the NP SIG from the list of all ONS SIGs displayed.
  • Once the front page of the NP SIG Virtual Community appears, select “New User” from the top left. This allows you to create log-in credentials.
  • Type the required information into the text fields as prompted. Click “Finish” (at the bottom right of the text fields) when complete.
Special notice
  • If you already have log-in credentials generated from ONS Online, use this information instead of attempting to generate new information. If you created log-in credentials for ONS Online and wish to have different log-in information, you will not be able to use the same e-mail address to generate your new credentials. Instead, use an alternate e-mail address.
Subscribe to the Nurse Practitioner SIG Virtual Community Discussion Forum
All members are encouraged to participate in the NP SIG’s discussion forum. This area affords the opportunity for exchange of information between members and nonmembers on topics specific to all oncology subspecialties. Once you have your log-in credentials, you are ready to subscribe to the NP SIG Virtual Community Discussion Forum. To do so, follow these steps.
  • Select “Log In,” located next to “New User,” and enter your information.
  • Next, click on the “Discussion” tab on the top right of the title bar.
  • Now, select “Featured Discussion” from the left drop-down menu.
  • Locate and select “Subscribe to Discussion” inside the Featured Discussion section.
  • Go to “Subscription Options” and select “Options.”
  • When you have selected and entered all required criteria, you will receive a confirmation message.
  • Click “Finish.”
  • You are now ready to begin participating in the NP SIG’s Discussion Forum.
Participate in the Nurse Practitioner SIG Virtual Community Discussion Forum
  • First, log in. This allows others to identify you and enables you to receive notification (via e-mail) each time a response or new topic is posted.
  • Click on “Discussion” from the top title bar.
  • Select “Featured Discussion” from the left drop-down menu.
  • Click on any posted topic to view contents and post responses.
Sign Up to Receive Nurse Practitioner SIG Virtual Community Announcements
As an added feature, members also are able to register to receive their SIG’s announcements via e-mail.
  • From the NP SIG Virtual Community page, locate the “Sign Up Here To Receive Your SIG’s Announcements” section. This appears right above the posted announcements section.
  • Select the “Click here” feature, which will take you to a link to subscribe.
  • Once the “For Announcement Subscription Only” page appears on screen, select how you wish to receive your announcements.
    • As individual e-mails each time a new announcement is posted
    • One e-mail per day comprised of all new daily announcements posted
    • Opt-out, indicating that you will frequently browse the NP SIG Virtual Community page for new postings
  • Enter your e-mail address.
  • Click on “Next Page.”
  • Because you have already joined the NP SIG Virtual Community, you will receive a security prompt with your registered user name already listed. Enter your password at this prompt and click “Finish.”
This will bring up a listing of your SIG’s posted announcements. Click on “My SIG’s Page” to view all postings in their entirety or to conclude the registration process and begin browsing.

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Special Interest Group Newsletter  August 2003

Recruit New Members, Earn Valuable Prizes

Get involved in the ONS Member-Bring-a-Member (MBAM) Campaign for a chance to earn valuable rewards. Participating is easy! Tell your colleagues about the many benefits of ONS membership and invite them to join. You need to recruit only one member to earn your initial reward. From there, the more members you recruit, the more rewards you earn. In addition, if you recruit a new member, your efforts will be recognized in a special MBAM section of ONS Online.

MBAM has five prize levels.

  • Recruit one new member and receive a recognition pin.
  • Recruit three new members and earn an online continuing education registration.
  • Recruit five new members and receive a one-year ONS membership.
  • Recruit seven new members and receive a $25 ONS Foundation gift certificate.
  • Recruit 10 new members and receive a paid Congress or Institutes of Learning registration.
How does it work? Write your name in the “referred by” line at the top of a special MBAM application. Distribute these applications to your colleagues and encourage them to join ONS. Tell them about the value of membership and how ONS helps you to provide the best care possible to patients and their families. Let them know about the many member benefits the Society offers.

Each time a new member joins ONS using an application with your name listed as the referring member, ONS will enter the information into its database. As you reach each prize level, an ONS customer service representative will send you your reward and contact you if necessary to make arrangements for receiving your reward. ONS will keep track of all your referrals and contact you as you reach each level.

Special MBAM applications are available through ONS Customer Service and on ONS Online.

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Special Interest Group Newsletter  August 2003

Are You Interested in Learning More About Computers?

ONS now offers the “New Frontier . . . Computer Technology in Oncology Nursing” tool kit. The program is being presented at local chapters and offers education on computer usage to suit a wide range of needs—from basic to advanced. Chapters arrange to have a designated program speaker or a local chapter member present the program based on membership needs. Concepts learned can be integrated into practice, which, in turn, may impact quality cancer care.

If you want to learn more about using computers or brush up on your skills, contact your local chapter. Not a local chapter member? Visit ONS Online at www.ons.org to locate one near you.

Don’t let this opportunity pass you by. Stay on the cutting edge of technology with help from the New Frontier tool kit.

In the February 2003 issue of the Nurse Practitioner SIG Newsletter (Vol. 14, No. 1), the primary author of the article “How to Manage Cancer Pain Using Methadone” is Shirley Mauzoul. Her name was misspelled in the original article.
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Special Interest Group Newsletter  August 2003

Nurse Practitioner SIG Officers

Diane Cope, PhD, ARNP-BC, AOCN®
605 Astarias Circle
Fort Myers, FL 33919-3247
239-437-3571 (H)
239-437-4444 (O)

Ex Officio
Terri Armstrong, MS, APRN-BC
2908 Amherst St.
Houston, TX 77005-3018
713-665-0718 (H)
713-745-4621 (O)

Janet VanCleave, MSN, ACNP-CS, AOCN®
11 E. 87th St., Apt. 8A
New York, NY 10128-0578
212-289-7849 (H)
917-738-5474 (O)


Christie Hancock, APN, MSN, RN, CS, OCN®
1207 E. Country Club Terrace
Jonesboro, AR 72401-4324
870-935-4546 (H)
870-972-4510 (O)

ONS Publishing Division Staff
Elisa Becze, BA


Know someone who would like to receive a print copy of this newsletter?
To print a copy of this newsletter from your home or office computer, click here or on the printer icon located on the SIG Newsletter front page. Print copies of each online SIG newsletter also are available through the ONS National Office. To have a copy mailed to you or another SIG member, contact Membership/Leadership Administrative Assistant Carol DeMarco at carol@ons.org or 866-257-4ONS, ext. 6230.

ONS Membership/Leadership Team Contact Information
Angie Stengel, BA, Director of Membership/Leadership

Diedrea White, BA, Manager of Member Relations and Diversity Initiatives

Carol DeMarco, Membership/Leadership Administrative Assistant

The Oncology Nursing Society (ONS) does not assume responsibility for the opinions expressed and information provided by authors or by Special Interest Groups (SIGs). Acceptance of advertising or corporate support does not indicate or imply endorsement of the company or its products by ONS or the SIG. Web sites listed in the SIG newsletters are provided for information only. Hosts are responsible for their own content and availability.

Oncology Nursing Society
125 Enterprise Dr.
Pittsburgh, PA 15275-1214
ONS Online: www.ons.org

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