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NNP Group 2: Financial Analysis_________________________________________Presented toDebra Armentrout, PhD, MSN, RN, NNP-BCTHE UNIVERSITY OF TEXASSCHOOL OF NURSING AT GALVESTON_________________________________________In Partial FulfillmentOf the Requirements for the CourseGNRS 5350: Nurse Practitioner – Professional Roles & Business Practices___________________________________ByTracey Causer, Katie Lawton, Gabriela Olivas, Ashley RobsonJuly 20th, 2014NNP Group 2: Financial AnalysisIn this paper, we will be exploring the financial analysis of a healthy uncomplicated preterm 28 week female in the ten week course of stay in the Neonatal Intensive Care Unit (NICU). The various costs associated with the care of this infant will be analyzed, including admission charges, charges in the level III and the level II stay, medications, lab work, radiological studies, nutritional screens and discharge screens. We will also include what is charged versus what is actually reimbursed. The purpose of the financial analysis is to also explore whether it is beneficial and profitable for a Neonatal Nurse Practitioner (NNP) to bill for the charges incurred rather than bill under his/her collaborating physician. Breakdown of Charges/Explanation of ChargesICD-9, CPT and Diagnoses Charges for the NICU are verified using ICD-9 diagnostic codes. ICD-9, or International Classification of Diseases, is a code system used to describe patient’s signs, symptoms, injuries, disease and conditions (UFHealth, 2014). These codes facilitate billing, so it is imperative that the nurse practitioner have correct documentation on his/her patients to support charges billed in order to be properly reimbursed. The correlation between ICD-9 codes and CPT codes is in reference to medical billing and reimbursement. CPT, or Current Procedural Terminology, is used to identify the medical, surgical, radiology, laboratory, anesthesiology, and evaluation/management services provided by the health care professionals and the hospital (UFHealth, 2014). Basically ICD-9 described a patient’s condition, whereas CPT identifies services and supplies provided to the patient (UFHealth, 2014). For a hospital to receive reimbursement from government and insurance agencies, every CPT code billed must correspond with an appropriate ICD-9 code to ensure it was medically necessary for the patient and their condition. If these codes don’t correlate together, the hospital is not reimbursed for the services or supplies provided. The diagnoses listed in Chart A will justify the expenditures for the purpose of this analysis. Chart A: Diagnoses & ICD-9 codes for an uncomplicated 28 week neonateSalary InformationTable 1 represent`s the staff involved in the care of the 28 weeker over the ten week period the patient is in the NICU. It ranges from the Neonatologist to the Equipment tech. The respiratory therapist is only involved in the patient’s care until the neonate reached 32 weeks post conceptual age, where he did not need any further respiratory support because he was on room air. The occupational therapist involved with the patient from the beginning by addressing development positioning to oral motor stimulation once the patient starts to feed. The equipment tech is involved in the care by continuous restocking the patient`s needed supplies. The salaries of the staff may not be directly billed, but it is included in the total billing for the NICU hospitalization.Table 1 Costs of staff related to 28 week infant stay in the NICUEmployeeHourly WageHours per DayDays UsedTotal CostNeonatologist$72.002470$120,960Neonatal Nurse Practitioner$45.002470$75,600Registered NurseRespiratory Therapist $35.00$32.00 24 247028 $58,800$21,504Occupational Therapist$35.00146$1575Equipment Tech$15170$1050TOTAL $279,489.00Admission ChargesCharges for this patient begin at birth; this patient was born via C-Section. Initial cost begins with attending delivery to stabilization of the neonate to admission in the NICU. The patient was intubated on two occasions to receive surfactant. He did not need to remain intubated, so he is initially placed on nasal CPAP. He does receive a chest x-ray on admission, umbilical artery/umbilical venous placement for IV access. A chest x-ray is obtained to evaluate lung fields related to prematurity. The neonate will need long term access for IV nutrition, so umbilical venous lines are placed. The vein hydration charge is for the initial 30-60 minutes of fluids given to stabilize the neonate. The umbilical arterial catheter is placed for the purpose of monitoring the patient’s blood pressure (Gomella, Cunningham, & Eyal, 2013). Table 2 represents the cost of admission, as well as the reimbursement for the items billed.Table 2 Costs associated with admission into NICU (FHCCL, 2014)Admission related chargeCPT CodeTotal Estimated ChargeAttending at delivery &1st stabilization of newborn 99464$76.95Critical Care Evaluation & Management99291$250.09Initial Inpatient Critical Care per day 28 days<99468$1137.20Intubation, Endotracheal, Emergency Procedure31500$121.84 x 2=$243.68Intrapulmonary Surfactant Administration94610$74.60 x 2=$149.20Chest X-Ray frontal71010$30.42Umbilical Artery Catherization36606$675.00Umbilical Vein Catheterization36510$625.00Abdomen X-Ray74000$48.00Blood Gas82803$32.00Vein Hydration first 30-60 minutes96630$180.00Continuous Pulse OximetryTotal Charges:94760$66.00 x 70 days = $4620.00$8067.54Level II & Level III Bed ChargesThe neonate will be staying the in the NICU; the NICU consists of varying levels of care. Due to the fact this is an uncomplicated 28 week neonate, his stay in level III will be three weeks, and the other seven weeks will be in the less acute level II. The information in Table 3 represents the bed charges for the stay per day in each of these levels.Table 3 Charges for Total Stay in the NICULevel of Care in NICUTotal daysCost per dayTotal Cost Level III 21$4160.00 $87,360.00Level II49 $3145.00$154,105.00Total$241,465.00CPT Codes & NICU StayThe level III, level II stay to discharge in the NICU for this 28 week neonate incurred the following CPT codes as shown in table 4.Table 4 CPT codes related to a 28 week neonates NICU stayCPT related chargeCPT CodeAmount of DaysCost per dayTotal Estimated ChargeNICU Daily<28 days of age9946927$2150.00$58,050.00NICU Daily > 29 days of age9946542$1540.00$6468.00Discharge992381$189.00$189.00Discharge Hearing Screen 925511$24.99$24.99Total Cost$64,731.99Modes of Respiratory SupportInitially the neonate is intubated for surfactant administration. The remainder of the hospital stay, the neonate only requires nasal CPAP x 14 days. The other 14 days the neonate is on a nasal cannula starting at 2 liters per minute eventually decreasing to 1 liter per minute until he is on room air by day of life 28. Table 5 illustrates the costs associated with the mode of respiratory support.Table 5 Cost of Modes of Respiratory Support for a 28 week Neonate (Dayton Children’s Hospital, 2014)Respiratory Method of SupportCost per dayDay on supportTotal CostNCPAP$695.0014$9730.00Nasal Cannula$101.0014$1414.00TOTAL: $11,144.00Lab WorkOver the course of the 10 weeks, the infant will require labs to analyze blood to evaluate blood components, serum chemistries, oxygenation status and infection. We would expect a 28-week infant, with an uncomplicated course through hospital stay, to have a complete blood count (CBC) with differential upon admission and every morning, for the first three days of life. While the infant is on parenteral nutrition, we would continue to monitor the serum chemistries, after the first 24 hours of life and every morning. By day of life 6, the infant would be on 80 mL/kg/day of enteral feeds and I would discontinue the intravenous fluids. After the first 24 hours of life, the infant will need a total serum bilirubin (TSB) to evaluated bilirubin and a newborn screen. Triglyceride levels are ordered to assess the infant’s tolerance to intralipids and evaluated increasing dose. With a sepsis evaluation, the patient would need a blood culture ordered, as well. Table 6 illustrates the total cost for laboratory studies for this patient post admission. Chemstrips are ordered to assess for hypoglycemia or hyperglycemia in the neonate (Gomella et al., 2013). Finally hematocrit levels and retic counts are ordered to assess for the need of blood transfusions. The premature neonate has frequent blood draws, so it is imperative to assess for anemia and the need for a blood transfusion as well.Table 6 Total Laboratory Cost for a 28 week neonate NICU stay (FHCCL, 2014)Laboratory TestCPT CodeCostQuantity ordered during NICU stayTotal CostCBC with differential85025$37.004$148.00Basic Metabolic Panel80048$53.004$212.00Newborn Screen83788$40.002$80.00Total Serum Bilirubin 82247$27.005$135.00Triglycerides84478$39.503$118.50Arterial Blood Culture87040$65.001$65.00Chem Strips82948$20.0010$200.00Hematocrit85014$35.008$280.00Retic Count85049$35.004$140.00Total Cost $1481.50SuppliesOver the course of the 10 weeks of the infant’s hospital stay, they will utilize various supplies from diapers, wipes, IV flushes, IVs, IV tubing, EKG leads, and feedings supplies. On a daily inquiry, the infant would approximately use 8 diapers/day and a box wipes/week. While increasing the infant’s feeds, the infant will remain on IV fluids. We expect the infant, over the 6 days of need for IV fluids to need 3 IVs, 6-8 IV flushes/day and one set of IV tubing every 4 days. Prior to taking all PO feeds, the infant will need supplies for gavage feeding. Throughout the hospital stay, we expect the infant to need 3 NG feeding tubes, and 7 feeding connections/day. Table 7 illustrates the total cost for supplies for this patient post admission.Table 7 Total Supplies Cost during 28 week NICU StayTestEach CostCharge to Patient?Diapers?$1.50??????????????$44.00Wipes$2.00?????????????$20.00IV start kits$6.00?????????????$18.00IV flushes$1.25?????????????$54.00IV tubing$15.00 $30.00NG tubes$0.52 $1.56Feeding Tubes$1.50 $84.00Total Cost $251.56Procedures, Treatments and Medical InterventionsRadiological StudiesInitially after delivery and upon admission in the NICU, the infant will need a chest x-ray to evaluate the lung fields and indicate need for further medical interventions. Since the infant has been declared to have an uncomplicated course, I would expect the infant to only need 1 x-ray. Along with x-ray, the infant will need a head ultrasound to assess for intracranial hemorrhage. Table 8 illustrates the total cost for radiological studies for this patient post admission.Table 8 Total Cost for Radiological Studies in a 28 week neonate NICU stayRadiological ProcedureCost for patientChest AP$220.00Head Ultrasound $370.00Total Cost$590.00PhototherapyPremature infants have an higher risk for hyperbilirubinemia because they have susceptibility to infection and have decreased amount of serum albumin, than in the term infant (Gomella et al., 2013). Treatment for hyperbilirubinemia includes phototherapy, which is usually initiated following an increased serum bilirubin value. For a 28-week infant, with an uncomplicated case, we would expect the infant will need phototherapy by DOL 4 and be completed with therapy by DOL 6. Table 9 illustrates the total cost for phototherapy for this patient post admission.Table 9 Total Cost for Phototherapy in a 28 week neonate NICU stayTestCost per DayCharge to Patient?Phototherapy$112.00/day????????????? $336.00Phototherapy Eye Shield $3.75 Total Cost $339.75ROPThroughout the 10 weeks, a 28 week infant may need to undergo various procedures and interventions to assess for complications associated with prematurity. In the 28 week infant, exposure to increased oxygen support can lead to devastating complications of retinal detachment and blindness. Infants born prior to 30 weeks gestation and?weight <1500 grams that have required cardiopulmonary support are at an increased increased risk for ROP (AAP, 2013). Based on the initial exam, the stage and occurrence of ROP identifies the schedule for follow-ups. For an ROP exam, the infant would be billed for ROP exam completed by optometrist, the eye kit and medications used in the exam. For the 28 week infant, we would expect the infant to receive to 2 ROP screens. Table 10 illustrates the total cost for ROP screens for this patient post admission.Table 10 Total Cost for ROP screen in a 28 week neonate NICU stayTestCost/TestCharge to Patient?ROP exam?$66.00$132.00ROP examination kit$53.00$106.00Cyclomydril $270.00$27.00Proparacaine$9.00$9.00Total Cost$274.00?Medications/FluidsReimbursement When discussing reimbursement, we must discuss Medicaid. Medicaid is a program that assists individuals pay for high healthcare costs and custodial care. This program is funded by the federal government, but run by state programs. As nurse practitioners, we are considered the primary care provider, and need legislation in place for reimbursement. Even though we have been considered the primary care provider under the fee for service system since 1990, we need legislation to facilitate the proper functions of practitioners. The Balanced Budget Act of 1997 has some misleading wording that inhibits the amount of healthcare for the vulnerable population. However, practitioners have been found to be extremely valuable as a resource for state Medicaid fee for service (AANP, 2013). The changes that need to be made in the Federal Medicaid law are: fee-for-fee service Medicaid to include direct payment, recognize all practitioners as primary case managers, and require NPs, CNSs, and CNMs to be included in Medicare managed care (ANA, 2013). Through the Collaboration of the Centers for Medicare and Medicaid Services (CMS), the goal is to have increased payments to primary care case managers. The Center for Medicare and Medicaid Services has an improving infant and maternal health campaign. Improving the health of the infants and mothers we encounter can decrease health care cost long term. Quality improvement projects are focused on early elective deliveries. Programs that exist are: strong start for Mothers and Newborns Initiative, Text4baby State Launch, and Building Bridges between Public Health and Medicaid (Centers for Medicaid and CHIP Services, 2014).Under Medicaid there is a Provider Statistical and Reimbursement System (PS&R). This tool is helpful for institutional healthcare providers. This system puts together reimbursement data applicable to the finalized Medicare Part A claims. Users may access their own Provider Summary reports using the PS&R Redesign user interface screens. Prior to accessing the system, you first need to register for a user ID and password in Center for Medicare and Medicaid Services Individual Authorized Access (IACS). (CMS, 2014).Medicaid coverage varies from state to state according to requirements. The payment is usually lower than available through insurance. The average reimbursement expectation is 50-55% of billable charges.Private InsurancePrivate Health Insurance plan are carrier including: Blue Cross Blue Shield, Aetna, Prudential, and Metropolitan. The traditional fee-for-fee service provided by private insurance companies functions to reimburse providers for patient charges. Similar to Medicaid reimbursement, private insurance reimbursement varies from state to state. Advanced Practice Nurses should contact each insurance company for credentialing and reimbursement protocols. Cash and credit card payingThe cash payment option is rare but does happen. As an advanced practice nurse, we may choose to take cash or credit forms of payment. Also, a practice owner needs to make a decision on whether to have a credit option for their customers (Hanson & Bennett, 2014).Summary of ease or difficulty of success in and independent NNP practiceReferencesAANP. (2013). Retrieved from Academy of Pediatrics. (2013). Screening examination of premature infants retinopathy of prematurity. Retrieved from .org/content/131/1/189.full.AANP. (2013). Retrieved from , 2013. Retrieved fro for Medicaid and CHIP Services, 2014). Retrieved from Centers for Medicare and Medicaid Services, 2014. Retrieved fro Children’s Hospital. (2014). Pricing. Retrieved from .org/cms/site/pricing/index.htmlFair Health Consumer Cost Lookup [FHCCL]. (2014) Retrieved from , T. L, Cunningham, M. D. & Eyal, F. G. (2013). Neonatology: Management, procedures, on-call problems, diseases and drugs (7th Ed.). New York: McGraw Hill EducationHanson, C. M., & Bennett, S. D. (2014). Business planning and reimbursement. In A. B. Hamric, J. A. Spross, & C. M. Hanson. (Eds.). Advanced nursing practice: an integrative approach (5th ed., pp. 505 - 537). St. Louis: Elsevier-Saunders.UFHealth (2014). What is a CPT code? Procedural and diagnosis coding must be linked by medical necessity. Retrieved from ................
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