A project that provides a support structure to NPs transitioning to direct billing at the Children’s Hospital of Philadelphia (CHOP) Emergency Department (ED) was linked to increased confidence in clinical-decision making and charting as well as increased job satisfaction, according to findings presented at the National Association of Pediatric Nurse Practitioners (NAPNAP) virtual conference held April 26 to 29, 2022.

Nurse practitioners at the CHOP Emergency Department began independently evaluating, treating, and billing for low acuity patients starting in 2013. However, the transition to direct billing has been inconsistent and has been typically delayed, occurring during the second or third year of experience.

With the many benefits of NP direct billing (increased revenue, improved timely access to care for lower acuity patients, and greater flexibility for provider staffing) comes increased responsibility and the pressure of decision-making and meeting specific metrics, explained study authors Emily Hardy, MSN, CPNP-AC, and Patricia Lopez, MSN, CPNP-PC/AC, of CHOP.

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To provide a formal transition process when preparing NPs for direct billing, researchers developed an onboarding model that includes the ED NP Direct Billing Guide. This electronic reference guide includes information on charting (Figure), common urgent care complaints, procedures, and not-to-miss diagnoses.

Figure. Example charting section of the ED NP Direct Billing Guide at CHOP. Image courtesy of Hardy and Lopez

A direct billing shadow shift is also arranged. As part of the transition process, NPs direct bill in the first 2 months for lower acuity patients within their acute care teams and are gradually assigned specific direct billing shifts. Feedback and further support is provided at a follow-up meeting.

Outcomes of NP Direct Billing Program

Six NPs implemented the transition program to direct billing over a period of 18 months at CHOP. The program was linked to increased confidence in clinical-decision making, charting, and formulating differential diagnoses, as assessed in pre- and postintervention surveys. An increase in role satisfaction was also found at 6 months following the intervention.

“EDs considering integration of NPs may consider this onboarding model when preparing NPs for direct billing,” noted Hardy and Lopez. Portions of the program may also be used to prepare NPs working in other departments for direct billing, the noted.

The researchers plan to further examine the effectiveness of this intervention over the next year.


Hard E, Lopez P. Supporting the transition to direct billing for CHOP emergency department nurse practitioners. Poster presented at: NAPNAP National Conference on Pediatric Health Care; April 26-29, 2022