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Medicare Physician fee schedule final rule (CMS): impact on APRNs/RNs.

The Medicare Physician Fee Schedule Final Rule, issued November 1, 2012 by the Centers for Medicare & Medicaid Services (CMS), will have a major positive impact for many RNs and APRNs, especially those working in primary care, care coordination, psychiatric/ mental health, and anesthesia services Overall, this rule includes new Current Procedural Terminology (CPT) codes and payments for transitional care management and psychiatric services It also clarifies that CRNAs can provide chronic pain management-and other-services consistent with state scope of practice rules.

ANA dedicated significant resources that influenced the outcome of this regulation, including our ongoing, active participation on the CPT Editorial Panel and the Relative Value System Update Committee (RUC). It is here where the CPT codes are developed and valued ANA also submitted comments on the proposed rule ( The 1,362-page Final Rule will be effective starting January 1, 2013 and can be accessed via the CMS website (; the Federal Register version will appear around November 16.

Transitional Care Management (TCM) Services:

With 15-20% of Medicare beneficiaries re-admitted within 30 days of discharge from hospitals, CMS has agreed to begin paying for transitional care management (TCM) services designed to prevent such readmissions. This decision represents a major step forward in recognizing the value and contributions of nurse care coordinators and APRNs who provide these services-which many physician groups acknowledged throughout the CPT & RUC processes. This decision is also a departure from CMS' longstanding reluctance to pay for any non face-to-face services.

CMS will pay physicians and "qualified nonphysician practitioners" for tCm services in the 30 days after a Medicare beneficiary leaves a hospital, skilled nursing facility, or community mental health center partial hospitalization program. The Final Rule adopts 2 new CPT codes for TCM Each requires contacting the patient within 2 business days of discharge; a face-to-face visit within 14 or 7 calendar days; moderate or highly complex medical decision-making; and detailed care coordination activities One provider-usually a primary care provider, but a specialist, when appropriate-can bill the service, per patient per discharge Nurse practitioners, clinical nurse specialists, and certified nurse midwives are specifically authorized to use these codes. The Final Rule states "As for nonphysician qualified health care professionals, we believe only NPs, PAs, CNSs, and certified nurse midwives (CNMs) can furnish the full range of E/M [evaluation and management] services and complete medical management of a patient under their Medicare benefit to the limit of their state scope of practice."

CMS also adjusted the clinical labor time for non face-to-face care management by the nurse and will compensate this work using the (higher) RN/LPN mix, consistent with ANA's position that most care coordination work is done by RNs, rather than the customary (lower) RN/LPN/MA (medical assistant) mix.

Complex Chronic Care Coordination (CCCC): The CPT Editorial Panel approved three new codes for CCCC services that could be billed separately In the final rule, CMS decided to bundle services rather than pay for these services separately Regardless of whether CMS decides in the future to reward these services for Medicare beneficiaries separately, ANA understands that private insurers are willing to use these individual codes, and are planning to reimburse them directly If these codes are widely used by private insurers, that could mean heightened recognition for nurse care coordinators--and more positions for RNs in this role Moreover, it is very rare to have CPT codes which represent services performed entirely by nurses. That is a victory in itself!

Psychiatry/Psychotherapy Services: Over several years, ANA has worked closely with the American Psychiatric Nurses Association (APNA), and others (APA/ psychiatry, AACAP/child and adolescent psychiatry, APA/psychology, and NASW/social work) to improve coding and reimbursement for psychiatric/mental health services Unfortunately, CMS set lower values for 10 out of the 12 new codes that were surveyed. But CMS plans to review the entire code set, taking RUC recommendations into account CMS also clarified time spent with family members is only billable insomuch as it helps the beneficiary, who must be present for a significant portion of the service APNA and ANA are currently planning a series of joint webinars explaining the new codes.

Pain Management by Nurse Anesthetists: ANA congratulates AANA, the American Association of Nurse Anesthetists, on CMS' decision to continue reimbursing certified registered nurse anesthetists (CRNAs) for chronic pain management for Medicare beneficiaries CMS is modifying its regulations to provide that "Anesthesia and related care means those services that a certified registered nurse anesthetist is legally authorized to perform in the state in which the services are furnished " When state scope of practice rules allow nurse anesthetists to provide chronic pain management services, Medicare will reimburse them CMS deliberately deferred "to individual states to determine the scope of practice for CRNAs" and avoided listing which services they can or cannot do under Medicare.

Portable X-Rays Ordered by APRNs: CMS will also modify its regulations to permit portable x-rays to be ordered by certain "nonphysician practitioners," including nurse practitioners, clinical nurse specialists, and certified nurse midwives. They are already permitted, under section 410. 32(a)(2), to order "diagnostic tests. "The Final Rule notes that "Nonphysician practitioners have become an increasingly important component of clinical care, and we believe that delivery systems should take full advantage of all members of a healthcare team, including nonphysician practitioners "

DME Face-to-Face Encounters: CMS clarified that nurse practitioners and clinical nurse specialists can conduct face-to-face encounters required for durable medical equipment (DME), but the statute requires a physician to document that encounter. The encounter must occur within 6 months before delivery of DME. The effective date is moved to July 1, 2013, because of changes in the final rule and the need to educate providers and beneficiaries.

Hepatitis B Vaccines: CMS will expand coverage of Hepatitis B vaccination and administration to individuals diagnosed with diabetes mellitus.
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Title Annotation:American Nurse Association
Publication:South Carolina Nurse
Date:Jan 1, 2013
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