An expert trainer in NGAP, Marielle Ducastel shares best practices for accurate pricing of medical care.
Recent changes to the nursing convention have led to significant modifications to the nomenclature of professional nursing acts (NGAP), with the aim of enhancing the value of homecare nursing services. How can this be optimized, while remaining above reproach with regard to the French health insurance system? Answers from Marielle Ducastel, NGAP expert trainer, as part of the DPC program.
Administration and monitoring of oral therapy in the home
An act reserved for patients with psychiatric disorders, it has been extended to people suffering from cognitive disorders (neurodegenerative or related diseases) since December1, 2019.
Subject to medical prescription, the doctor must specify on the prescription:
- the number of daily home visits,
- the need to work on Sundays and public holidays,
- the duration of the prescription.
Please note: after the first month, this procedure is subject to prior agreement.
Rating: AMI 1.2 per pass
Please note: the nomenclature calls for a surveillance sheet to be drawn up.
This procedure is subject to a Majoration Acte Unique (MAU) for each visit not associated with the dispensing of other nursing procedures.
Rider no. 6 clearly states that the MAU has been extended to single acts with a coefficient ≤ 1.5.
For the purposes of this rating, the notion of home does not include :
- health establishments mentioned in article L 6111-1 of the French Public Health Code,
- residential establishments for the elderly, handicapped or maladjusted adults mentioned in article 3.5 of law no. 75-535 of 30/06/1975, as amended,
- with the exception of the Résidences Autonomie.
Monitoring and observing a patient during treatment implementation or modification
As of December 1, 2019, the pre-existing rule of one daily passage is abolished.
The prescription period for this procedure is therefore no longer based on the number of days, but on the number of passages.
This evolution enables doctors to better adapt their prescriptions to the intensity of monitoring required in each case.
Any change in treatment may give rise to a new prescription if the doctor deems it necessary.
The quotation for this procedure is now: AMI 1 per visit instead of per day, up to a limit of 15 visits.
A MAU may be added for each visit not associated with the dispensing of other nursing procedures.
Please note: here again, the nomenclature calls for a surveillance sheet to be drawn up.
Weekly half-hour clinical nursing monitoring and prevention session
As of January1, 2022, this session is still applicable, but only to patients aged under 90. According to the BSI roll-out schedule, this quotation will be replaced by the new flat-rate pricing system for patients aged 85 to 89 from September 2022, and regardless of age in April 2023. During this transitional period, the AIS4 quotation for this session is now subject to the preparation of a BSI valid for one year.
They can only be dispensed once a week.
This act includes :
- control of the main parameters used for prevention and monitoring of the patient's state of health,
- checking treatment compliance and planning - monitoring patient comfort and safety,
- monitoring the adaptation of any personalized assistance program,
- keeping the monitoring record and transmitting information to the attending physician,
- keeping a liaison sheet and passing on information to family and friends or a third party acting in their place.
This procedure can only be quoted once a week: AIS 4.
What changes does the ISB bring? What happens to the weekly clinical monitoring session? Has it been replaced? Eliminated?
As of January1, 2020, the ISB will replace the ISD for all patients aged 90 and over. Rider 8, which adapts the conditions for deployment of the ISF, makes no changes for this age group. On the other hand, from January1, 2022, you will have to systematically establish a BSI on the lower age brackets in order to be able to quote an AIS4. From September 2022, lump-sum care pricing will be compulsory for dependent patients aged between 85 and 89. If the projected timetable is adhered to, from April 2023, all dependent patients will switch to BSI packages, which will replace the weekly clinical monitoring session.
In this context, many of you have asked yourselves the following question: "Since the weekly clinical monitoring session is subject to the drawing up of an ISD, won't it gradually disappear as the ISB takes over and no longer refers to this act?"
The answer from Marielle DUCASTEL, CPD expert trainer:
- At present, only patients aged 90 and over are eligible for flat-rate billing. However, you still have the option of monitoring these dependent patients at risk of medication-related iatrogenicity, within the framework of health insurance coverage. However, with BSI, you will no longer be paid on a fee-for-service basis, but on a lump-sum basis according to your daily or weekly care load.
- For younger age groups, as of January1, 2022, you must systematically draw up an ISB, but you will continue to bill in AIS. The option of performing and billing the "weekly clinical monitoring session" remains.
- From September 2022 for those aged 85 to 89, and from April 2023 for all ages, AIS quotations will be replaced by BSI packages, which will take the place of the weekly clinical session.
In conclusion, while AIS 4 weekly monitoring remains in force during this transitional period, depending on age, this quotation is set to disappear. However, under no circumstances will this change in nomenclature deprive you of the possibility of monitoring long-term poly-drug treatments with iatrogenic risk for dependent patients. Better still, for patients for whom you provide this care under AIS4, your intervention is limited to one session per week, which will no longer be the case with fixed-price pricing, as we shall see in the example below.
Example
Mr X will soon be celebrating his 90th birthday, and will no longer be able to benefit from a weekly clinical monitoring session once his current prescription expires. What can be done to ensure continuity in the monitoring of his multi-medication treatment?
You ask the doctor to prescribe a Bilan de Soins Infirmiers (BSI).
You can create your ISB online.
Assuming that MR X's case would lead you to select from the proposed nursing diagnoses in the medical section only one item in a single area of care :
- 1/ ☐ Chronic disabling pain with significant impact on quality of life
- 2/ ☐ Long-term multidrug therapy with iatrogenic risk
- 3/ ☐ Other (please specify): ....
The algorithm will suggest possible nursing interventions if at least one diagnosis is made:
| Care areas | Description of work performed and required | VALUE | GROUP |
Treatment | Monitor patients at risk of adverse drug events in collaboration with the physician and/or pharmacist: identify patients at risk of adverse drug events, ensure safe medication management, and manage risk situations and alerts. | 6 | T2 |
If Mr X is polymedicated, you can also propose educational care:
| Care areas | Description of work performed and required | VALUE | GROUP |
Educational care | Relational nursing care for dependent patients requiring:-educational assistance for patients with chronic pathology(ies) to acquire or maintain the skills they need for everyday life and for monitoring their treatment. | 6 | SE2 |
In this case, the algorithm will determine a light class rating (BSA) and you will be able to select a weekly frequency for these treatments.
Conclusion for Mr X, by moving from a DSI to the BSI, the quotation increases :
- AIS 4 for half an hour, 10.60€ (plus travel: IFD 2.50€) -Initial ISD 15€, valid for three months, 10€ for subsequent ISDs
- to a BSA without opposable duration of care, i.e. 13€ (plus displacement: IFI 2,50€) -Elaboration of the initial BSI 25€, valid one year, only one renewal per year 12€.
Good to know:
DSI: weekly clinical monitoring session.
BSI: you can program several packages per week.
In the example of Mr X, if in addition to the weekly BSA package, he requires a Durogesic-type transcutaneous device with pain assessment and monitoring by test requiring several visits per week, you can offer several weekly BSA packages.
You will also select ;
"Chronic disabling pain with significant impact on quality of life".
The algorithm will suggest a possible intervention in the area of pain care.
Another advantage of the BSA package over AIS 4 is that it can be combined with certain technical procedures (rated AMX under the BSI):
- at full rate in derogation of art. 11B of the NGAP with an infusion, a heavy and complex dressing, a blood test and a home session for clinical monitoring and prevention for a patient following hospitalization for an episode of decompensation of heart failure or an exacerbation of COPD,
- half price for other prescribed procedures.
Examples
- BSA with complex dressing: BSA + AMX 4 + MCI
- Combined BSA and blood sampling: BSA + AMX 1.5
- Combined BSA and IM injection: BSA + AMX1/2
