Article, Emergency Medicine

Nurse practitioners and physician assistants in emergency medical services who billed independently, 2012-2016

a b s t r a c t

Objective: As nurse practitioners and physician assistants become an integral part of delivering emer- gency medical services, we examined the involvement of NPs and PAs who billed independently in emergency departments (EDs).

Methods: We used Medicare provider utilization and payment data from 2012 to 2016 to conduct a retrospective analysis. We examined the changes in the number of each clinician type who billed independently for four com- mon emergency services (CPT codes: 99282-5), the change in their service volume, and the change in their av- erage number of services billed.

Results: Between 2012 and 2016, the proportion of NPs and PAs billing independently increased from 18% to 22% for ED visits of low severity (99282), 23% to 29% for visits with moderate severity (99283), 21% to 27% for visits with high severity (99284), 18% to 24% for visit with the highest severity (99285), and 23% to 29% across all four services. The proportion of services provided by emergency physicians decreased from 66% to 63% across all four services, and from 11% to 9% for internists and family physicians. The number of NPs, PAs billing independently, and emergency physicians increased by 65%, 35% and 12% respectively.

Conclusions: NPs and PAs are increasingly billing emergency services of all levels of severity, independent of phy- sicians. This trend is driven by a growing number of NPs and PAs independently billing services, despite a rela- tively stable number of emergency physicians (excepting the decline in rural areas), and diminished involvement of family physicians and internists in EDs.

(C) 2019

Introduction

The growing demand for emergency services accompanied by rela- tively stable supply of emergency physicians is necessitating changes in the clinician workforce in emergency departments (EDs) [1]. Increas- ing involvement of nurse practitioners (NPs) and physician assistants (PAs) is one important response to the growing demand as well as the ongoing effort of hospitals and clinician groups to control spending [2- 4]. NPs and PAs are increasingly being utilized in emergency care and their supply is forecasted to grow [1].

Prior studies estimated the proportion of ED visits seen by NPs and PAs independently (without direct physician involvement) were ap- proximately 7% during 1993-2005, 6% during 2006-2009 [5,6]. In 2014, almost 25% of emergency medicine clinicians were found to be

? The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. This research is not funded by any organization. We thank Tianxin Li for research assistance.

* Corresponding author.

E-mail address: [email protected] (G. Bai).

NPs or PAs [4]. Recent studies in specific geographic areas have found higher levels of NPs and PAs practicing independently of direct physi- cian involvement. Among EDs in Iowa in 2012, only 12% were staffed ex- clusively with emergency physicians and 61% had NPs/PAs working alone for at least part of the week [7]. In 2014, 46% of critical access hos- pitals in Washington had NPs and PAs in their EDs, 75% of which only had PAs see patients [8].

The current literature, however, has not examined the recent trends of NPs and PAs billing independently in EDs at the national level, in ag- gregation or for specific common service. In this study, we used the Medicare provider dataset to examine these national trends and discuss their implications.

Methods

Data

We used Medicare provider utilization and payment data from 2012 to 2016, a time period for which data are available, published by the Center for Medicare and Medicaid Services (CMS) [9]. Data includes

https://doi.org/10.1016/j.ajem.2019.01.052

0735-6757/(C) 2019

national provider identifier (NPI), Medical specialty, and Medicare utili- zation for clinicians who billed services to Medicare beneficiaries and submitted Medicare part B non-institutional claims. Under Medicare rules, NPs and PAs are allowed to deliver these services independent of direct physician involvement and bill Medicare under their own NPI. We excluded clinicians who reported less than $100 annual Medi- care allowed amount for each service billed to Medicare patients.

Common emergency services

Our focus was on four common ED evaluation and management ser- vices that are dominantly billed by emergency physicians and uniquely delivered in emergency settings. In 2016, four services were billed by more than 5000 emergency physicians: (1) ED visit with high severity (CPT code: 99284; by 36,866 emergency physicians, 63% of all clini- cians); (2) ED visit with highest severity (CPT code: 99285; by 36,727 emergency physicians, 67% of all clinicians); (3) ED visit with moderate severity (CPT code: 99283; by 34,090 emergency physicians, 62% of all clinicians); and (4) ED visit with low severity (CPT code: 99282; by 5544 emergency physicians, 64% of all clinicians). We excluded critical care initial 30-74 min (CPT code: 99251; by 26,616 emergency physi- cians, 44% of all clinicians), because less than half of the care was billed by emergency physicians.

Clinician types

We included five types of clinicians in our analysis: emergency phy- sician, family physician, internist, NP, and PA. These are the dominant

providers of common emergency services. In 2016, they represented 96%, of all clinicians who billed for ED visit with low severity (99282), and 97% of all clinicians who billed for ED visit with moderate severity (99283), high severity (99284), and highest severity (99285).

Variable measurement

We calculated the percentage of each type of clinician billing inde- pendently for each of the four services by dividing the number of a given type of clinician by the total number of PAs, NPs, emergency phy- sicians, family physicians, and internists who also billed the same ser- vice in each year. We measured the distributions of service as the number of service billed by a given type of clinician who billed indepen- dently divided by the overall number of service billed by the five types of clinicians in each year. In addition, we measured the average number of each service billed by each type of clinician in each year.

Statistical analyses

First, we conducted analyses at the level of clinician by studying the change in the number of each type of clinician and the change in the composition of clinicians from 2012 to 2016, for each common service and for all common services combined. Next, we conducted analysis at the level of service. For each common emergency service, we examined the change in the number of services for each type of clinician from 2012 to 2016 and the change in the composition of clinicians for each service. Moreover, we analyzed the change in the average number of service billed by each type of clinician to understand the trend of service

Table 1

Number of clinicians billing independently for Medicare beneficiaries, 2012-2016.

2012 2013 2014 2015 2016 2012-2016

CPT code: 99282 (ED visit, low to moderately severe problem)

NP

612 (5%)

541 (6%)

518 (6%)

591 (7%)

633 (8%)

3%

PA

1471 (13%)

1326 (14%)

1169 (13%)

1126 (13%)

1179 (14%)

-20%

Emergency physician

7776 (68%)

6583 (67%)

6104 (68%)

5842 (68%)

5544 (67%)

-29%

Family physician

1169 (10%)

1015 (19%)

846 (9%)

800 (9%)

721 (9%)

-38%

Internist

450 (4%)

357 (4%)

325 (4%)

294 (3%)

250 (3%)

-44%

Total

11,478 (100%)

9822 (100%)

8962 (100%)

8653 (100%)

8327 (100%)

-27%

CPT code: 99283 (ED visit, moderately severe problem)

NP

3246 (7%)

3630 (7%)

3968 (8%)

4493 (9%)

5139 (10%)

58%

PA

7533 (16%)

8266 (17%)

8817 (18%)

9305 (18%)

10,037 (19%)

33%

Emergency physician

31,663 (67%)

32,240 (66%)

32,992 (66%)

33,501 (65%)

34,090 (64%)

8%

Family physician

3358 (7%)

3269 (7%)

3088 (6%)

3036 (6%)

2978 (6%)

-11%

Internist

1523 (3%)

1443 (3%)

1327 (3%)

1221 (2%)

1190 (2%)

-22%

Total

47,323 (100%)

48,848 (100%)

50,192 (100%)

51,556 (100%)

53,434 (100%)

13%

CPT code: 99284 (ED visit, problem of high severity)

NP

3030 (6%)

3495 (7%)

3929 (8%)

4451 (8%)

5297 (9%)

75%

PA

7340 (15%)

8112 (16%)

8754 (17%)

9345 (17%)

10,187 (18%)

39%

Emergency physician

33,032 (69%)

34,135 (68%)

35,103 (67%)

35,917 (66%)

36,866 (65%)

12%

Family physician

3144 (7%)

3092 (6%)

3049 (6%)

3011 (6%)

3023 (5%)

-4%

Internist

1620 (3%)

1548 (3%)

1458 (3%)

1328 (2%)

1305 (2%)

-19%

Total

48,166 (100%)

50,382 (100%)

52,293 (100%)

54,052 (100%)

56,678 (100%)

18%

CPT code: 99285 (ED visit, problem with significant threat to life or function)

NP 2164 (5%)

2529 (5%)

2938 (6%)

3485 (7%)

4261 (8%)

97%

PA 5660 (13%)

6483 (14%)

7060 (15%)

7721 (15%)

8660 (16%)

53%

Emergency physician 32,512 (74%)

33,617 (72%)

34,591 (72%)

35,611 (70%)

36,727 (69%)

13%

Family physician 2366 (5%)

2362 (5%)

2421 (5%)

2457 (5%)

2511 (5%)

6%

Internist 1419 (3%)

1389 (3%)

1295 (3%)

1239 (2%)

1214 (2%)

-14%

Total 44,121 (100%)

46,380 (100%)

48,305 (100%)

50,513 (100%)

53,373 (100%)

21%

Across 4 CPT codes: 99282-99285

NP 3635 (7%)

4078 (8%)

4523 (8%)

5120 (9%)

5986 (10%)

65%

PA 8396 (16%)

9172 (17%)

9825 (18%)

10,454 (18%)

11,301 (19%)

35%

Emergency physician 33,968 (66%)

34,994 (65%)

35,983 (65%)

36,951 (64%)

38,037 (63%)

12%

Family physician 3755 (7%)

3644 (7%)

3503 (6%)

3456 (6%)

3425 (6%)

-9%

Internist 1943 (4%)

1835 (3%)

1740 (3%)

1605 (3%)

1531 (3%)

-21%

Total 51,697 (100%)

53,723 (100%)

55,574 (100%)

57,586 (100%)

60,280 (100%)

17%

Notes: The percentages in brackets indicate the ratio of the number of a given type of clinician to the total number of the five types of clinicians. The percentages in the column 2012-2016 indicate the change in the number of a given type of clinician between 2012 and 2016, ignoring changes in the middle years.

Table 2

Service volume billed by clinicians for Medicare beneficiaries, 2012-2016.

2012 2013 2014 2015 2016 2012-2016

CPT code: 99282 (ED visit, low to moderately severe problem)

NP

17,058 (5%)

14,787 (5%)

13,346 (6%)

15,349 (7%)

17,224 (8%)

1%

PA

38,257 (12%)

31,757 (11%)

26,207 (11%)

25,705 (11%)

27,666 (12%)

-28%

Emergency physician

216,092 (65%)

180,929 (65%)

164,072 (68%)

157,257 (67%)

144,831 (65%)

-33%

Family physician

43,555 (13%)

36,501 (13%)

28,506 (12%)

26,230 (11%)

24,132 (11%)

-45%

Internist

16,930 (5%)

12,410 (4%)

10,446 (4%)

9728 (4%)

8769 (4%)

-48%

Total

331,892 (100%)

76,384 (100%)

242,577 (100%)

234,269 (100%)

222,622 (100%)

-33%

CPT code: 99283 (ED visit, moderately severe problem)

NP

211,088 (6%)

224,368 (7%)

242,528 (7%)

266,121 (8%)

287,736 (9%)

36%

PA

515,113 (14%)

514,885 (15%)

534,644 (16%)

556,089 (17%)

570,146 (18%)

11%

Emergency physician

2,476,535 (69%)

2,318,820 (68%)

2,254,032 (67%)

2,194,873 (66%)

2,081,038 (65%)

-16%

Family physician

270,734 (8%)

243,384 (7%)

229,034 (7%)

218,952 (7%)

199,392 (6%)

-26%

Internist

122,876 (3%)

106,260 (3%)

94,273 (3%)

87,581 (3%)

78,425 (2%)

-36%

Total

3,596,346 (100%)

3,407,717 (100%)

3,354,511 (100%)

3,323,616 (100%)

3,216,737 (100%)

-11%

CPT code: 99284 (ED visit, problem of high severity)

NP

195,192 (3%)

216,520 (4%)

246,864 (4%)

284,277 (5%)

329,205 (6%)

69%

PA

474,665 (8%)

512,932 (9%)

570,657 (10%)

603,570 (11%)

655,866 (12%)

38%

Emergency physician

4,423,121 (79%)

4,350,345 (78%)

4,359,527 (77%)

4,340,623 (77%)

4,276,368 (75%)

-3%

Family physician

330,691 (6%)

312,804 (6%)

310,151 (6%)

306,927 (5%)

301,386 (5%)

-9%

Internist

171,456 (3%)

162,042 (3%)

148,170 (3%)

137,427 (2%)

128,739 (2%)

-25%

Total

5,595,125 (100%)

5,554,643 (100%)

5,635,369 (100%)

5,672,824 (100%)

5,691,564 (100%)

2%

CPT code: 99285 (ED visit, problem with significant threat to life or function)

NP

145,270 (1%)

169,147 (2%)

203,381 (2%)

254,849 (2%)

321,835 (3%)

122%

PA

390,360 (4%)

437,956 (4%)

507,251 (5%)

576,599 (5%)

673,337 (6%)

72%

Emergency physician

8,909,252 (88%)

9,038,401 (88%)

9,237,126 (87%)

9,556,004 (86%)

9,746,434 (85%)

9%

Family physician

410,836 (4%)

400,127 (4%)

418,896 (4%)

444,172 (4%)

464,825 (4%)

13%

Internist

286,716 (3%)

274,667 (3%)

248,187 (2%)

251,524 (2%)

253,250 (2%)

-12%

Total

10,142,434 (100%)

10,320,298 (100%)

10,614,84 (100%)

11,083,148 (100%)

11,459,681 (100%)

13%

Notes: The percentages in brackets indicate the ratio of the number of services billed independently by a given type of clinician to the total number of services billed by the five types of clinicians. The percentages in the column 2012-2016 indicate the change in the number of services billed for a given type of clinician between 2012 and 2016, ignoring changes in the middle years.

intensity. Finally, we repeated the analyses above for clinicians practic- ing in rural areas [10].

Results

Change in the number of clinicians for each service

Table 1 presents the changes in the number of clinicians who billed common emergency services between 2012 and 2016. For ED visit with low severity (99282), the number of all clinicians, except for NPs, de- clined between 2012 and 2016. For more severe ED visits (99283-99285), the number of NPs and PAs billing independently in- creased by at least 30%, the number of emergency physicians increased by 8-13%. These changes resulted in a growth in the proportion of PAs and NPs (from 23% to 29%) billing independently and a corresponding decline in the proportion of physicians (from 77% to 72%).

In Table 1, we also presented the proportional distribution of clini- cians who billed any of the four common emergency services. Overall, more clinicians participated in emergency care (a 17% increase 2012-2016). The proportion of PAs and NPs billing independently in- creased from 7% to 10% and 16% to 19%, respectively; the proportion of emergency physicians decreased from 66% to 63%, and the proportion of family physician and internists combined decreased from 11% to 9%.

Change in service volume

Table 2 presents the change in the number of services for each type of clinicians and the change in the proportion of services by each type of clinician. These changes are largely consistent with the trends shown in Table 1. For ED visit with low severity (99282), the total number of ser- vices billed by all clinicians declined. For ED visit with moderate and high severity (99283 and 99284), the proportion of services billed by PAs and NPs increased substantially (20% to 27% for 99283; 11% to

18% for 99284), which contrasts with the drop in the proportion of emergency physicians (69% to 65% for 99283; 79% to 75% for 99284) and of family physicians and internists combined (11% to 8% for 99283; 9% to 7% for 99284).

Table 3 Average annual number of services per clinicians billing independently for Medicare ben- eficiaries, 2012-2016.

2012 2013 2014 2015 2016 2012-2016

CPT code: 99282 (ED visit, low to moderately severe problem)

NP

28

27

26

26

27

-2%

PA

26

24

22

23

23

-10%

Emergency physician

28

27

27

27

26

-6%

Family physician

37

36

34

33

33

-10%

Internist

38

35

32

33

35

-7%

CPT code: 99283 (ED visit, moderately severe problem)

NP

65

62

61

59

56

-14%

PA

68

62

61

60

57

-17%

Emergency physician

78

72

68

66

61

-22%

Family physician

81

74

74

72

67

-17%

Internist

81

74

71

72

66

-18%

CPT code: 99284 (ED visit, problem of high severity)

NP

64

62

63

64

62

-4%

PA

65

63

65

65

64

0%

Emergency physician

134

127

124

121

116

-13%

Family physician

105

101

102

102

100

-5%

Internist

106

105

102

103

99

-7%

CPT code: 99285 (ED visit, problem with significant threat to life or function)

NP

67

67

69

73

76

13%

PA

69

68

72

75

78

13%

Emergency physician

274

269

267

268

265

-3%

Family physician

174

169

173

181

185

7%

Internist

202

198

192

203

209

3%

Notes: The percentages in the column 2012-2016 indicate the change in the average num- ber of services billed for a given type of clinician between 2012 and 2016, ignoring changes in the middle years.

For ED visit with the highest severity (99285), the total number of services billed independently by PA and NP almost doubled between 2012 and 2016, and that of physicians increased slightly, except for in- ternists. Although emergency physicians still billed the vast majority of services (85%) in 2016, the proportion dropped from 88% in 2012, while the proportion of services independently billed by PAs and NPs in- creased (5% to 9%).

Change in the average number of service per clinician

Table 3 presents the changes in the average number of service billed per clinician in the period of 2012-2016. For ED visits with low and moderate severity (99282 and 99283), the average number of service billed per clinician dropped at comparable rates across all five clinician types. For ED visits with high and highest severity (99284 and 99285), the average number of service per emergency physician is the highest, followed by family physician and internist.

Clinicians in rural areas

The trends in rural areas, as summarized in Table 4, are similar to the overall trends shown in Tables 1-3, with two notable distinctions. First, the number of emergency physicians who provided emergency services dropped by 5% in rural areas (overall: grew by 12%) from 2012 to 2016, which leads to a reduction of the proportion of emergency physicians among the five clinicians from 47% in 2012 to 44% in 2016 (overall:

66% to 63%). Second, only half of moderate emergency services (99282-3) in rural areas were provided by emergency physicians in 2016 (overall: 65%); fewer than 70% of more severe services (99284- 5) in rural areas were provided by emergency physicians in 2016 (over- all: 75-85%).

Discussion and conclusions

Our CPT-code-level temporal trend analysis complements the recent demonstration of the ED workforce [4]. We found that between 2012 and 2016, relative to ED physicians, both the size and the average ser- vice volume of PAs and NPs who independently billed expanded. The number of emergency physicians increased but their proportion de- creased slightly. The involvement of family physicians and internists in emergency care declined. Specifically, the proportion of NPs and PAs billing independently increased from 18% to 22% for ED visits of low severity (99282), 23% to 29% for ED visits with moderate severity (99283), 21% to 27% for ED visits with high severity (99284), 18% to 24% for ED visit with the highest severity (99285), and 23% to 29% across all four services. The proportion of services provided by emergency phy- sicians decreased from 66% to 63% across all four services, and from 11% to 9% for internists and family physicians. The number of NPs, PAs billing independently, and emergency physicians increased by 65%, 35% and 12% respectively. Taken together, the involvement of NPs and PAs in emergency care, as measured by independent billing, has increased for patients of all levels of severity examined, and is expanding fastest in

Table 4

Clinicians billing independently for Medicare beneficiaries in rural areas, 2012-2016.

Number of clinicians Number of service Average

2012 2016 2012-2016 2012 2016 2012-2016 2012 2016 2012-2016

CPT code: 99282 (ED visit, low to moderately severe problem)

NP

159 (7%)

215 (12%)

35%

5961 (6%)

7406 (12%)

24%

37

34

-8%

PA

293 (12%)

220 (12%)

-25%

10,135 (10%)

6739 (11%)

-34%

35

31

-11%

Emergency physician

1256 (51%)

920 (51%)

-27%

50,129 (52%)

31,272 (50%)

-38%

40

34

-15%

Family physician

588 (24%)

367 (20%)

-38%

24,779 (26%)

13,482 (22%)

-46%

42

37

-13%

Internist

143 (6%)

76 (4%)

-47%

6149 (6%)

3610 (6%)

-41%

43

48

10%

Total

2439 (100%)

1798 (100%)

-26%

97,153 (100%)

62,509 (100%)

-36%

CPT code: 99283 (ED visit, moderately severe problem)

NP

689 (10%)

1024 (15%)

49%

44,525 (7%)

67,771 (13%)

52%

65

66

2%

PA

1004 (15%)

1240 (18%)

24%

77,506 (12%)

82,828 (16%)

7%

77

67

-13%

Emergency physician

3357 (49%)

3162 (46%)

-6%

376,940 (58%)

276,497 (52%)

-27%

112

87

-22%

Family physician

1470 (21%)

1194 (17%)

-19%

118,864 (18%)

82,480 (16%)

-31%

81

69

-15%

Internist

357 (5%)

282 (4%)

-21%

34,060 (5%)

21,454 (4%)

-37%

95

76

-20%

Total

6877 (100%)

6902 (100%)

0%

651,895 (100%)

827,030 (100%)

-19%

CPT code: 99284 (ED visit, problem of high severity)

NP

616 (9%)

1054 (15%)

71%

44,483 (5%)

80,850 (10%)

82%

72

77

6%

PA

943 (14%)

1223 (17%)

30%

74,484 (8%)

98,399 (12%)

32%

79

80

2%

Emergency physician

3418 (51%)

3248 (46%)

-5%

584,586 (66%)

492,029 (59%)

-16%

171

151

-11%

Family physician

1356 (20%)

1207 (17%)

-11%

137,676 (16%)

122,852 (15%)

-11%

102

102

0%

Internist

368 (5%)

304 (4%)

-17%

39,339 (4%)

32,900 (4%)

-16%

107

108

1%

Total

6710 (100%)

7036 (100%)

5%

880,586 (100%)

827,030 (100%)

-6%

CPT code: 99285 (ED visit, problem with significant threat to life or function)

NP

413 (7%)

816 (13%)

98%

26,571 (2%)

70,569 (6%)

166%

64

86

34%

PA

686 (12%)

1015 (16%)

48%

56,291 (5%)

101,309 (8%)

80%

82

100

22%

Emergency physician

3282 (59%)

3145 (51%)

-4%

859,331 (75%)

838,385 (69%)

-2%

262

267

2%

Family physician

913 (16%)

935 (15%)

2%

143,655 (13%)

154,962 (13%)

8%

157

166

5%

Internist

312 (6%)

273 (4%)

-13%

54,749 (5%)

55,196 (5%)

1%

175

202

15%

Total

5606 (100%)

6184 (100%)

10%

1,140,597 (100%)

1,220,421 (100%)

7%

Across 4 CPT codes: 99282-99285

NP

772 (10%)

1208 (16%)

56%

PA

1111 (15%)

1364 (18%)

23%

Emergency physician

3506 (47%)

3333 (44%)

-5%

Family physician

1653 (22%)

1384 (18%)

-16%

Internist

437 (6%)

335 (4%)

-23%

Total

7479 (100%)

7624 (100%)

2%

Notes: The percentages in brackets indicate the ratio of the number of a given type of clinician to the total number of the five types of clinicians. The percentages in the column 2012-2016 indicate the change in the number of a given type of clinician between 2012 and 2016, ignoring changes in the middle years. Rural areas were identified based on the zip codes where clinicians practiced.

severe coded services for conditions with the high complexity. This trend, accompanied by a slightly growing number of emergency physi- cians and a declining number of family physicians and internists, sug- gests an increasingly important role played by NPs and PAs in EDs. Their role is becoming especially prominent in rural areas due to the de- cline in the number of emergency physicians, family physicians, and in- ternists practicing there.

While most states have laws regulating NP/PA practice, such as re- quiring physician review of PA medical records [6], no regulation or guideline exists regarding how EDs should make staffing decisions based on the severity of episodes or at what level of severity NPs and PAs can provide emergency care. The limited supply of emergency phy- sicians to meet the demand of emergency services and the development of training programs to prepare NPs and PAs for emergency care may be responsible for the trend of growing involvement of NPs and PAs in emergency care [4,11]. In rural areas, attracting a full complement of emergency physicians can prove difficult and the involvement of NP/ PA in emergency care is more pronounced [4].

Higher utilization of NP/PA is also attributable to the development of emergency care oriented NP/PA training programs. An increasing num- ber of postgraduate training programs have been established to prepare NPs and PAs for emergency care [12,13]. The challenge is how to com- bine the expertise and advantages of emergency physicians and NPs/ PAs to deliver effective and cost-conscious care. The response to this challenge will have important implications on the education and train- ing of all clinician types and the practice of emergency medicine by all clinicians involved.

This study has several limitations. First, CPT codes reflect strength of documentation as much as provider involvement and patient severity. We relied on CPT codes since initial Emergency Severity Index in- formation was not in the dataset. Second, we do not have data to iden- tify the facility where emergency clinicians practice and thus cannot examine the potential variation of NP/PA utilization across facilities. Third, the potential quality difference across different types of emer- gency clinician, which cannot be addressed using our data, remains a promising topic for future research to explore. Fourth, the generalizabil- ity of this study might be limited since Medicare patients do not repre- sent the overall patient population served by emergency clinicians. Fifth, the occurrence of discretionary coding cannot be addressed

using the data. Finally, the independence in billing by NPs and PAs does not necessarily indicate their independence in care delivery by NPs and PAs. Who primarily delivered care for each visit cannot be de- termined from our data.

References

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  9. CMS. Medicare provider utilization and payment data: physician and other supplier. Available from: https://www.cms.gov/Research-Statistics-Data-and-Systems/ Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and- Other-Supplier.html.
  10. CMS. DME rural zip and formats. Available from: https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule- Items/DME-Rural-Zip-and-Formats.html?DLPage=1&DLEntries=10&DLSort= 2&DLSortDir=descending, Accessed date: 26 January 2019.
  11. Martsolf GR, Barnes H, Richards MR, Ray KN, Brom HM, McHugh MD. Employment of advanced practice clinicians in physician practices. JAMA Intern Med 2018;178 (7):988-90.
  12. Kraus CK, Carlisle TE, Carney DM. Emergency medicine physician assistant (EMPA) postgraduate training programs: program characteristics and training curricula. West J Emerg Med 2018;19(5):803-7.
  13. Wilbeck J, Roberts E, Rudy S. Emergency nurse practitioner core educational content. Adv Emerg Nurs J 2017;39(2):141-51.

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