Building Capacity to Provide Physical and Behavioral Health Services to Persons with Low Incomes

Background: Building robustness for health programs serving vulnerable populations – including undocumented residents - require financial sustainability in order to continue in the neoliberal environment. To achieve this objective, we sought to improve sustainability for a system of not-for-profit university-based physical and behavioral health clinics. This was achieved through an examination of nursing education funded through a HRSA funded Nursing Education Practice, Quality, and Retention (NEPQR) grant. Nursing education and the provision of social work support services were examined through reviewing logs maintained by BSN level nursing students related to their learning experiences and use of appropriate diagnostic ICD-10 and DSM codes. This serves a two-fold purpose of developing practical nursing skills while examining the relevance of potential billing codes in primary care nursing and behavioral health assessment. Nursing students from George Mason’s College of Health and Human Services collaborated with the Department of Social Work to provide physical and mental health services. This exploration of seeks to understand the relationship between service provision and billing codes that potentially build financial capacity for publicly-funded clinics.

Methods: We implemented a qualitative content analysis method with data were collected during a two-month period of weekly logs maintained by BSN nursing students. The nursing student logs were facilitated via Qualtrics surveys and documented ICD-10 codes related to the nurse’s weekly duties. BSN student activities, attitudes and perspectives were captured by two MSW level research assistants who identified appropriate billing codes through a review of student logs. Twenty-six viable ICD and DSM billing codes were identified. Estimated per service billing levels were then identified based on the expected provider of service (e.g., RN, DPN, MSW) ranged from approximately 40% to 50% of what a licensed physician could bill. Frequency distributions of the identified codes were compiled with the estimated billing amounts in order to estimate potential revenue.

Results: Findings indicate that significant funding could potentially be generated through identifying and billing. ICD and DSM diagnoses were identified for: Persons encountering health services for examinations, Persons with potential health hazards related to communicable diseases, Encounters for other specific health care, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, Body mass index (BMI), Persons encountering health services in other circumstances, and Persons with potential health hazards related to family and personal history and certain conditions influencing health status. Using these billing codes at the appropriate Medicaid approved rates were shown to significantly enhance the financial stability of the training and were essential to maintaining the approach beyond the grant funding cycle.

Implications: The NEPQR training demonstrated that there is significant potential to positively address racial and social justice by generating billing to justify services through observing the application of knowledge by students in not-for-profit clinics. Increasing the quality of nursing care for Medicaid populations may provide health benefits that lessen health discrepancies across disadvantaged populations. Potential problems were identified including billing mechanisms which could cause a lag in receiving the potential revenue and capacity of universities to have an adequate billing system.