Nurse Practitioner Frequently Asked
Questions
Introduction and Purpose
This document was origionally prepared in 2000 by Michigan
Nurses Associaton (MNA) Congress on Nursing Practice
members Janice Locke, Chairperson; Delores Rustic, Debra
Parker and MNA staff member Jan Coye. Special thanks
are owed to many nurses who provided input, recommendations
and support for this document. It has been updated regularly
through input from many NPs.
About the Michigan Nurses Association
This publication is a service of the Michigan Nurses
Associaton. As the professional association for all
registered nurses in Michigan, MNA makes it possible
for nurses to speak with ONE STRONG VOICE to address
the practice, political and professional issues that
affect RNs in this state -- decisions that impact your
practice every day. This publication is one example
of the quality services provided to address the concerns
and issues of nurse practitioners in Michigan.
Permission to Reproduce
The Michigan Nurses Associaton grants permission for
the user to reproduce this document using an appropriate
credit line.
| Information regarding rules, regulations and
reimbursement changes frequently. The reader is
advised to ensure that all such information pertaining
to practice is current. |
Introduction and Purpose
As the number of nurse practitioners completing their
education increases, so does the number of questions
relating to nurse practitioner practice. The offices
of Michigan Nurses Association (MNA) receive many calls
from members and nonmembers alike asking for clarification
of issues - both professional and clinical in nature.
The following document, created by a subcommittee of
the MNA Congress on Nursing Practice, is intended to
provide guidance for the most commonly asked questions
related to professional issues of Nurse Practitioner
practice in the state of Michigan. The answers provided
are summaries of the information gathered from several
resources. While every attempt has been made to ensure
accurate and up to date information, it is the responsibility
of each individual to consult the original source for
more in-depth coverage of the issue in question.
The Michigan Board of Nursing Administrative Rules
for Nurse Specialty Certification provide the opportunity
for some clinical nurse specialists (CNSs) certified
by the American Nurses Credentialing Center to be State
of Michigan certified as nurse practitioners. The term
"nurse practitioner" as used in this document includes
these CNSs, as well as NPs, who qualify for NP certification
according to the Michigan Board of Nursing Rules.
The content within this document, which is presented
in question and answer format, is targeted for NPs.
However, many of the issues and items could apply to
other advanced practice nurses (APNs) which is a category
that includes nurse practitioners, nurse midwives, nurse
anesthetists, and clinical nurse specialists.
Accessing Michigan
Laws and Administration Rules
There are a number of references in this publication
to Michigan laws and rules, To access this information,
go to www.cis.state.mi.us/bhser.
To locate a rule (the citation will begin with R), click
on administrative rules and locate Board of Nursing,
Board of Medicine, or Board of Osteopathic Medicine.
What are the limitations
on my practice before I have obtained Michigan Board
of Nursing Certification?
Prior to obtaining Michigan Board of Nursing certification
as a nurse practitioner the registered nurse may not
"hold herself/himself out to the public" (see R338.10403)
as a nurse practitioner. That means you cannot call
yourself or allow others to call you a nurse practitioner,
you cannot use NP in your credentials, nor can you allow
your patients or your employers to believe that you
have achieved the legal status of nurse practitioner.
Without Michigan Board of Nursing certification you
cannot obtain a provider number for Medicaid, Blue Cross
or Medicare, or for any other third party nurse practitioner
reimbursement (Medicare makes certain exceptions for
clinical nurse specialists). Therefore, until you have
the State of Michigan NP certification, you are a registered
nurse (RN), and should call yourself that.
The nurse's education and experience determine the
scope of practice of any RN, and all nurses should practice
in a manner consistent with that education and experience.
All nurses are responsible and accountable for recognizing
the limits of their knowledge and skill. The nurse practitioner
program you have completed enlarges your scope and enables
you to practice using the knowledge, skill and judgment
you learned in the nurse practitioner program. However,
just as you may not call yourself a nurse practitioner
until you are State of Michigan certified, you may not
seek reimbursement as an NP until you are certified.
How do I become certified
by the State of Michigan as a nurse practitioner?
Nurses in Michigan may not use the title "nurse midwife,"
"nurse anesthetist "or" nurse practitioner" unless they
have achieved nurse specialty certification from the
Michigan Board of Nursing. The Board of Nursing uses
the term "certified" for these specialists as a way
of acknowledging the certification processes of specific
national nursing organizations.
The Occupational Regulation Sections of the Michigan
Public health Code, Act 368 of 1978, provides the Board
of Nursing with this authority:
333.17210 Registered professional nurse; issuance
of specialty certification; qualifications.
Sec. 17210. The Board of Nursing may issue a specialty
certification to a registered professional nurse who
has advanced training beyond that required for initial
licensure and who has demonstrated competency through
examination or other evaluative processes and who practices
in one of the following health profession specialty
fields: nurse midwifery, nurse anesthetist, or nurse
practitioner.
The Board of Nursing Nurse Specialty Certification
rules state (R338.10401-10406): R338.10403 Advertisement
of services. Only nurses certified in a nursing specialty
field may hold themselves out to the public as nurse
specialists using the title nurse anesthetist, nurse
midwife, or nurse practitioner. Conduct contrary to
this rule is deemed a violation of section 16221(g)
of the act. (Occupational Regulation Sections of the
Michigan Public Health Code.)
R338.10404(3) A specialty certification for nurse
practitioner shall be granted to a registered nurse
who satisfies all of the following requirements:
- Holds a current and valid license to practice nursing
in Michigan.
- Has a Bachelor of Science degree, or higher degree,
in nursing.
- Submits an application for certification in a specialty
area of nursing, on a form provided by the department,
and the required fee.
- Has successfully completed a formal advanced program
for nurse practitioners that consists of a combination
of didactic and clinical training with a minimum of
120 hours or 30% of the program's hours, whichever
is less, devoted to classroom theory and a minimum
of 360 hours or 30% of the program's hours, whichever
is less, devoted to supervised clinical practice in
the specialty area. The program shall encompass a
minimum of one academic year or nine months.
- Meets the advanced practice certification standards
of the American Nurses Credentialing Center, the National
Certification Board of pediatric nurse Practitioners
and Nurses, the National Certification corporation
for the Obstetric and Gynecologic and Neonatal Nursing
Specialties, the American Academy of Nurse practitioners,
or the Oncology Nursing Certification Corporation.
Nurses who wish to achieve nurse specialty certification
must make application to the Michigan Board of Nursing
demonstrating that they have met the eligibility requirements
that are detailed in the rules and request an application
for nurse specialty certification. It is easiest if
you send a self-addressed stamped envelope. The application
requires official transcripts from the education program
and evidence of certification mailed directly from the
appropriate certifying body. A fee is required and the
term of specialty certification is concurrent with the
nurse's RN license.
Contact the Michigan Dept. of Consumer and Industry
Services; Office of Health Services; 611 W. Ottawa St.
PO Box 30670; Lansing, MI 48909.
How do I explain my
scope of practice as a nurse practitioner?
The Occupational Regulation Sections of the Michigan
Public Health Code Act 368 of 1978 as amended contains
the following definition of nursing in Michigan, which
serves as the legal scope of practice statement. Registered
Nurses are licensed to practice independently within
this scope. When doing medically delegated functions
such as prescribing supervision by the delegating physician
is required.
Part 172
333.17201. (a) As used in this part: (a) "Practice
of nursing" means the systematic application of substantial
specialized knowledge and skills derived from the biological,
physical, and behavioral sciences, to the care, treatment,
counsel, and health teaching of individuals who are
experiencing changes in the normal health processes
or who require assistance in the maintenance of health
and the prevention or management of illness, injury,
or disability.
In the Michigan Public Health Code, all health professionals
have a broad definition of their practice such as the
above and definitive tasks or roles are not encoded
for any specialty area for any health occupation. Therefore,
the State of Michigan does not delineate by law a scope
of practice specific to nurse practitioners.
A nurse practitioner is a registered nurse with advanced
education and training in a healthcare specialty area.
All nurses are responsible and accountable for recognizing
the limits of their knowledge and skill.
In the state of Michigan, nurse practitioners practice
within a scope of practice defined by their specialty
education and training. The depth of scope of practice
is further defined by the knowledge base of the nurse
practitioner, the role he/she is in, and the client
population within the practice environment. The American
Nurses Association has developed two publications to
assist nurse practitioners in explaining their scope
of practice: Scope and Standards of Advanced Practice
Registered Nursing and Standards of Clinical Practice
and Scope of Practice for the Acute Care Nurse Practitioner.
The American Academy of Nurse Practitioners has also
developed a publication, Scope and Standards for the
Nurse Practitioner.
Specialty nursing organizations have also developed
scope and standards statements for nurse practitioners.
The following are generic functions applicable to most
nurse practitioner roles:
- Comprehensive physical examination and health assessment
- Promotion and maintenance of health
- Prevention of illness and disability
- Management of health care during common acute and
stable chronic illnesses
- Assessment of clients that includes analysis, synthesis,
and application of nursing theories and modalities
- Health counseling and guidance
- Admission of clients to hospitals/long term facilities
with management within these facilities
- Consultation and/or collaboration with other health
care providers or community resources
- Referral to other health care providers and community
resources
- Diagnosis of health/illness status
- Application of evidenced-based practice and research
skills
- Prescription and/or administration of medications,
therapeutic devices and measures
- Ordering and interpreting lab tests and X-rays
- Client advocacy
How are standards applicable
to my nurse practitioner practice?
Standards are authoritative statements by which the
nursing profession describes the responsibilities for
which its members are accountable, and reflect the values
and priorities of the profession. Standards provide
direction for professional nursing practice and a framework
for evaluation of practice. They are written in measurable
terms and define the nursing profession's accountability
to the public and the client outcomes for which nurses
are responsible.
An overview of the scope and standards for advanced
practice nursing is found in Scope and Standards of
Advanced Practice Registered Nursing. American Nurses
Association 1997, and developed by the American Nurses
Association for the profession in collaboration with
numerous specialty organizations. These standards provide
an overview of advanced practice registered nursing
and provide a more detailed and specific description
of a specialty's practice and describes a competent
level of professional performance common to all nurses
engaged in the specialty. This document can be used
as a tool for job descriptions, evaluation of performance
and guidelines for practice.
How is
supervision defined in the Michigan Public Health Code?
Section 333.16109 (2) contains the following definition
of supervision.
"Supervision", except as otherwise provided in this
article, means the overseeing of or participation in
the work of another individual by a health professional
licensed under this article in circumstances where at
least all of the following conditions exist:
- The continuous availability of direct communication
in person or by radio, telephone, or telecommunication
between the supervised individual and a licensed health
professional.
- The availability of a licensed health professional
on a regularly scheduled basis to review he practice
of the supervised individual, to provide consultation
to the supervised individual, to review records, and
to further educate the supervised individual in the
performance of the individual's functions.
- The provision by the licensed supervising health
professional of predetermined procedures and drug
protocol.
What authority
do NPs have to prescribe in the state of Michigan?
To understand and explain nurses prescriptive authority
in Michigan you'll need to have four documents:
1. Occupational Regulation Sections of the Michigan
Public Health Code Article 15, Part 161
- 333.16104(1) definition of delegation
- 333.16109(2)(a)(b)(c) definition of supervision
- 333.16215(1) linkage of delegation to supervision
- Part 170 medicine 333.17048(5) physician authority
to delegate prescribing to Pas
- Part 175 Osteopathic Medicine and Surgery 333.17548(5)
physician authority to delegate prescribing to
PAs
- Part 177 Pharmacy Practice and Drug Central
333.17708(2) definition of prescriber
2. Attorney General Opinion #5630 dated January 22,
1980
3. Board of Medicine rule 338.2304/338.2305
4. Board of Osteopathic Medicine rule 338.108a/338.108b
Use these four documents to explain nurse's prescriptive
authority this way:
Since 1978 the Occupational Regulation Sections of
the Michigan Public Health Code provided physicians
(both allopathic and osteopathic) with the authority
to delegate the function of prescription of drugs. Because
the law was specific to PAs, in 1980 the Michigan Nurses
Association asked the attorney general to issue an opinion
concerning the authority of a physician to delegate
prescribing to a registered professional nurse. The
opinion concludes that other than controlled substances
the legislature has permitted a physician to delegate
the prescribing of a drug to a licensed professional
nurse, but the physician may not delegate unlimited
authority to prescribe. A summary of the limitations
from the opinion is as follows:
- The physician delegates the prescribing of only
those medications which fall within the physician's
scope of practice
- Delegation of prescribing is to licensed professional
nurses (RNs) who are qualified by education (academic
education to prescribe is found in advanced nursing
programs), training or experience
- The physician supervises the delegation
- The physician may not delegate prescribing which
requires the physician's level of education, skill
and judgment
- Prescription of controlled substances could not
be delegated (this changed in November 1999, and may
now be done in accordance with specific rules as described
in the remainder of this explanation)
MNA was successful in promoting new rules, authorizing,
but not requiring allopathic and osteopathic physicians
to delegate the prescribing of controlled substances
to nurse practitioners. These rules became effective
November 17, 1999.
The new rules are based on 1978 statutory authority
contained in the Public Health Code since its inception.
However, administrative rules were required to fully
implement this authority.
Administrative Rules 338.2304/338.2305 (Medicine) and
Rules 338.108a/338.108b (osteopathic) have identical
requirements for physicians who elect to delegate the
prescribing of controlled substances to the physician's
assistants, nurse practitioners, or nurse midwives they
supervise.
When delegating Schedule 3 to 5 controlled substances,
the rules require a supervising physician to:
- Establish a written authorization (which should
be kept at each site of practice) containing the signatures
and license number of both parties
- Record limitations or exceptions to the delegation,
if any
- Document the effective date of the delegation
- Review and update the authorization annually and
record amendments, if any
The rules provide that Schedule 2 controlled substances
can only be delegated if both the delegating physician
and the physician's assistant, nurse practitioner, or
nurse midwife are practicing within a hospital, freestanding
surgical outpatient facility, or hospice. In this instance,
a prescription cannot be issued for more than a 7-day
period to a patient who is being discharged. The Michigan
Official Prescription Program rules (333.7334) apply.
The rules also prohibit a physician from delegating
the prescription of a drug or device individually, in
combination, or in succession for a woman known to be
pregnant with the intention of causing miscarriage or
fetal death.
- A delegated prescription must bear the name of
the physician who delegates. This applies to delegated
prescribing of controlled and non controlled substances.
Drug Enforcement Agency (DEA)
The Drug Enforcement Agency (DEA) requires nurse practitioners
and nurse midwives to obtain DEA numbers for prescribing
controlled substances.
To obtain your own DEA number, contact the regional
DEA office at 800/230-6844
The DEA now has forms on-line for registration of advanced
practice nurses. The application form can be found on
the web at the Diversion Control Program web site: www.DEAdiversion.usdoj.gov.
At the website, select "Drug Registration," then "Registration
Applications." The form is available in PDF format.
It is necessary to have Adobe Acrobat or Adobe Acrobat
Reader to access the form.
The information you'll need to send with your application
for a DEA number includes:
- A copy of your written agreement with a physician
for delegation of controlled substances
- A copy of your specialty organization (e.g. ANCC,
etc) certification and number
What are the requirements
for countersignature by the collaborating physician
on prescriptions and documentation written by a Nurse
Practitioner?
There is no state or national legal requirement for
physician countersignature of nursing documentation.
The Public Health Code Sections 333.17201-333.17242,
333.17001-333.17084 and 17708 do not require physician
countersignature. The pharmacy section of the Public
Health Code specifically states the delegating physician's
name must be "used, recorded or otherwise indicated"
(Public Health Code Section 333.17708 #2) when prescriptions
are being written by other licensed health professionals.
The Public Health Code Sections 333.16104(1) - definition
of delegation, 333.16109(2) - definition of supervision,
and 333.16215(1) - linkage of delegation to supervision
help in describing the roles/functions in a collaborative
agreement. There is no mention of countersignature requirements.
Third party payers have specific rules and requirements
related to reimbursement and so the reader should be
familiar with the rules and requirements of the specific
third party payers involved.
As a nurse practitioner, can I order, under my own
signature, physical therapy, speech therapy, occupational
therapy, labs, x-rays, home health services and any
other studies or therapies?
Physical therapy (PT) is the only modality, of those
listed in the question, addressed in the Michigan Public
Health Code and is under Part 178, Physical Therapy,
333.17820. That Michigan law states that physical therapy
is provided only upon the prescription of a physician,
dentist or podiatrist. The Michigan Public Health Code
is silent regarding who may or may not order the other
types of tests and treatments.
Hospitals, labs, and other providers of these services,
as well as third party payors, may or may not have their
own rules stating who may order such modalities. For
instance, you may be required to have privileges at
a hospital to order lab, x-rays, etc. there. You should
also be informed of which payors will reimburse for
services ordered by NPs. Most payors are silent on this
issue, but Center Medicare/Medicaid Services CMS (formerly
HCFA) specifically states that NPs may order labs and
x-rays. However, CMS also states that NPs may NOT order
home health care services.
What is credentialing
and privileging for nurse practitioners?
Credentialing is a process for validating professional
licensure, clinical experience, educational preparation
and certification for specialty practice. Typically
licensure or specialty certification assures a minimum
standard of educational preparation, specialty knowledge
attainment, and clinical experience. Credentialing also
assures adherence to educational standards established
by the state nurse practice acts (Public Health Code
in Michigan).
Requirements for credentialing may include, but are
not limited to the following:
Curriculum vitae, current RN licensure to practice,
graduation from an approved APN program, Certification
by an appropriate national credentialing body, state
specialty certification as either a certified nurse
practitioner (CNP), Certified nurse midwife CNM, or
certified registered nurse anesthetist (CRNA); letters
of recommendation from professional colleagues one or
more of whom may be an APN or physician with clinical
privileges at the institution of application, job description/
outline of specific clinical services to be provided
by the APN, Health clearance release form, malpractice
coverage policy, recent BCLS/ACLS certification.
Clinical Privileging: An entitlement process whereby
an APN is granted authority to provide health care treatment
in a hospital or other health care facility. Hospital
privileges are granted to the practitioner by the credentialing
body of the hospital as prescribed by hospital bylaws.
Privileging may also include the designation of specific
aspects of care within the institution.
Some of the more common activities for which an APN
could receive privileges are to perform history and
physical exams; order and monitor lab tests, x-rays,
diet, etc.; prescribe medications according to state
law; document client interventions; prescribe treatment
modalities; initiate consultations and referrals; conduct
care conferences/family meetings; share on-call responsibilities;
interface with other health care providers; admit and
discharge patients; assist and perform minor surgical
procedures. Other specific procedures for which the
APN is qualified may be listed.
May RNs take orders from nurse
practitioners?
A common situation where NPs might write orders that
would be directed to other RNs for implementation is
in a hospital. Usually the hospital has a system for
privileging nurse practitioners and it is clear as to
what the NP may order both as independent nursing orders
and as physician delegated medical activities.
As we know, NPs (and all nurses) do not have legal
authority to prescribe/order medications. However, they
may prescribe as a delegated function from a physician.
If an NP writes an order for medication, the name of
the delegating physician must be included on the order.
An RN (non-NP) may accept an order written in this fashion.
When an NP independently orders something that one
might consider a "nursing" activity, and which is within
the scope of nursing practice, such as instructions
to ambulate a patient, the RN certainly can accept the
order if the practice environment allows for NPs to
write orders. Anything ordered by an NP, under the NP's
name alone (no physician name), must fall within the
scope of practice of the NP.
What can nurse practitioners do
in the long-term care setting?
State and Federal guidelines regarding the delegation
of tasks to NPs in the long-term care setting can be
found in the Guidance to Surveyors - Long-term Care
Facilities in the sections under Tag Number F385 - F397
(Regulation number §483.40 - Physician Services).The
American Health Care Association publishes a book, The
Long Term Care Survey, that has the regulations and
guidance for surveyors. They have a website, www.ahcabookstore.org
and their address is 1201 L Street, NW: Washington,
DC 20005.
The NP may make every other required visit to the
resident and may perform delegated tasks that fall within
the scope of practice as defined by state law including
examining the resident, reviewing the resident's total
program of care, writing progress notes and signing
orders. A collaborative agreement must be in place between
the NP and the primary/attending physician and the NP
cannot be an employee of the long-term care facility.
Typical Functions/Roles of a Nurse Practitioner in
a Long-Term Care setting
- Write admission H&Ps - the attending must also
write a brief note to indicate that he/she saw the
patient and sign the NP's H&P
- Do every other required visit (for example every
other month for a patient who needs to be seen every
30 days)
- Write and sign orders
- Manage chronic long term problems (within the NP
scope of practice) such as monitoring blood sugars
and adjusting medication dose as needed
- Evaluate patients experiencing acute problems and
in consultation with the attending, order appropriate
treatment
- Provide informal (and formal) education for the
staff of the facility to help improve the knowledge
base of the nursing staff and to improve the quality
of care provided.
An NP can bill Medicare for direct reimbursement for
services provided that fall within the NP scope of practice
and are normally services covered by Medicare. Medicare
reimburses NPs at 85% of the amount approved for physician
reimbursement. Other insurance reimbursement (e.g. HMOs)
should be investigated on an individual basis.
What national quality care improvement
projects are Michigan nurse practitioners participating
in?
Quality care improvement projects are developed utilizing
Continuous Quality Improvement (CQI) to improve the
process and outcomes of care. CQI uses a scientific
approach to examine a process through the collection
and analysis of data. Meaningful data is used to understand
a process based on facts and to design effective and
lasting improvements.
Three (3) national quality care improvement projects
focus on improving performance on specific clinical
quality measures or quality indicators.
The current national quality care initiatives are:
- HEDIS - The major activity in managed care has been
the mandatory adoption of Health Plan Employer Data
and Information Set (HEDIS) performance measures for
all managed care organizations. For additional information,
visit http://www.ncqua.org.
- DQIP - The Diabetes Quality Improvement Project
(DQIP) was developed in 1997 under the sponsorship
of the Centers for Medicare and Medicaid Services
(CMS), formerly the health Care Financing Administration,
and with a coalition of major stake-holders in diabetes
care. Diabetes clinical quality indicators are measured
using a DQIP abstraction tool. For additional information
visit website http://www.hcfa.gov/quality/3L.htm.
- HCQIP - The Health Care Quality Improvement Program
is intended to improve the quality of care for Medicare
beneficiaries nationwide. In Michigan, the Michigan
peer Review Organization is working with CMS on a
number of projects to improve the processes and outcomes
of care for Michigan Medicare beneficiaries.
MPRO has organized CMS' six (6) clinical topics into
two (2) areas: prevention and Treatment. Prevention
encompasses breast cancer, diabetes, and adult immunizations
(influenza and pneumococcal pneumonia) in the ambulatory
care setting. Treatment topics include acute myocardial
infarction, heart failure, community-acquired pneumonia,
and stroke prevention in the inpatient setting.
MPRO is committed to decreasing health disparities
by increasing mammography screenings among Michigan's
African-American women. MPRO also offers assistance
to Managed Care Organizations (MCOs) that have Medicare+Choice
contracts. For more information, visit the following
websites: http://www.hcfa.gov/quality or http://www.mpro.org.
Websites for Quality Improvement
Michigan Peer Review Organization - http://www.mpro.org
Centers for Medicare and Medicaid Services - http://www.hcfa.gov/quality
National Committee for Quality/HEDIS Assurance - http://www.ncqa.org
Agency for Health Research and Quality - http://www.ahcpr.gov
Joint Commission on Accreditation of Health Care Organizations
- http://www.jcaho.org
Best Practice Network - http://www.best4health.org
How do NPs obtain reimbursement
for their services?
Third party payors determine which practitioners and
providers they will pay for covered services. All practitioners
and providers who receive reimbursement need to be recognized
by the payor.
There are two ways to receive reimbursement for NP
services:
- Direct, with the Nurse Practitioner's (NP's) name
and number on the claim, and for which reimbursement
may or may not be the same as what the physician receives
for the same service; or,
- Indirect, with the supervising physician's name
and number on the claim, and for which reimbursement
is the approved amount for physicians and is paid
to the supervising physician (or practice).
What third party payors provide
reimbursement for nurse practitioner services?
In Michigan, the following payors provide reimbursement
to NPs:
Medicaid - recognizes NPs (also CNMs and CRNAs) and
provides direct reimbursement
Medicare Secondary ("Gap") Payors - Many commercial
insurances recognize NPs, as Medicare does, and provide
direct reimbursement
Federal Insurances - Champus, BC/BS Federal and Railroad
Medicare recognize NPs (also CNMS and CRNAs) and provide
direct reimbursement
Blue Cross/Blue Shield of Michigan - recognizes NPs,
CNMs and CRNAs, and provides direct reimbursement
Commercial Insurances & Traditional Indemnity
Plans - Although it varies among companies, many recognize
NPS and provide direct reimbursement
HMOs - There are 29 licensed HMOs in Michigan. Many
of the 19 HMOs that provide Medicaid services will allow
NPS to have provider status and receive direct reimbursement.
However, the majority, with a few exceptions, of HMOs
licensed for commercial business do not allow NPs to
be o their provider panels. Therefore, it is important
to inquire of each HMO what its policies are. Typically,
reimbursement for services provided by NPs is obtained
indirectly, under the physician's name and number.
What are the
billing criteria for NP reimbursement?
Unfortunately, there is not one set of billing criteria
or requirements that all third party payors use for
either type of reimbursement for services provided by
NPs. Third party payors vary substantially; therefore,
it is critical that all NPs understand the basics of
reimbursement and the specifics of how claims are being
submitted to all payors for services they provide. A
good place to start is with Medicare because it has
the most defined criteria that must be followed.
What are the requirements for
direct reimbursement from Medicare?
For a service to quality for Medicare reimbursement,
the service must be medically necessary and must be
Medicare covered. Additionally, the practitioner providing
the service, e.g. the NP, must be legally authorized
to perform the service. It must be within the practitioner's
scope of practice. The other specific requirements for
direct reimbursement are:
- "Collaboration" --- not supervision -- with a physician
must exist
- A written "collaboration agreement" with the physician(s)
must be in place
- Claims must be submitted with the NP's name and
NP's Medicare provider number
Note the following:
- No direct supervision from a physician is required
(except that required for prescriptive authority)
- The physician does not have to see the patient or
be present in the office at the time of service
Following is the definition of collaboration as defined
in the 1989 Omnibus Budget Reconciliation Act, Medicare
regulations:
"Collaboration is a process in which a nurse practitioner
works with one or more physicians to deliver health
care services within the scope of the practitioner's
professional expertise, with medical direction and appropriate
supervision as provided for in jointly developed guidelines
or other mechanisms as provided by the law of the State
in which the services are performed."
What are the requirements for
indirect (incident to) reimbursement from Medicare?
Medicare calls billing and receiving payment under
a physician's name for services provided by an NP "incident
to" reimbursement. This means that the service:
- Was furnished "incident to" the professional services
of a physician, where the physician initiates the
course of treatment and establishes the plan of care;
- Was furnished under the direct personal supervision
of the physician, which means that the physician must
be present in the office/suite and able to see the
patient when the NP renders the service;
- Was provided by an NP who is an employee of the
physician (or clinic);
- Was medically necessary;
- Is Medicare-covered;
- Is commonly provided in a physician office/clinic;
- Is billed under the physician's name with the modifier
"YR".
Direct personal supervision, as defined by HCFA (now
CMS) means that there must have been a direct, personal,
professional service furnished by the physician to initiate
the course of treatment. The service being performed
by the nonphysician practitioner is an incidental part,
and there must be subsequent services by the physician
of a frequency that reflects his/her continuing active
participation in and management of the course of treatment.
In addition, the physician must be physically present
in the same office suite and be immediately available
to render assistance as needed.
In a clinic situation where several physicians and
practitioners are working, Medicare recognizes and will
pay for services where one physician orders the service
and another one supervises. The same physician does
not have to see the patient for ongoing management of
care, or to supervise the NP.
As of July 2001, CMS (formerly HCFA), via federal
regulations, has stated that the physician must see
the patient initially and establish the plan of care.
However, they have not stated how frequently after the
initial visit the physician must actually provide services
to demonstrate active participation in and management
of the patient. They, CMS, also have not stated that
the physician must see the patient for each new problem
However, the administrators for the Medicare program,
Wisconsin Physicians Service (WPS) for Michigan, may
require additional criteria, such as the physician seeing
the patient for each new problem.
Communication with WPS in July 2001 revealed they
also do not have "specific" criteria for "incident to",
but they do look for physician involvement in the treatment
program, as the general Medicare regulations require.
If "incident to" must be used, one piece of advice was
to have a policy in the office as to how often the physician
would see the patient and for what new problems, and
to have all NP notes reflect frequent consultation with
the physician on the management plan.
Most other payors do not use "incident to" as Medicare
does, but may allow billing under the physician's name
when their specific requirements for supervision are
followed. It is important and necessary to identify
what each payor's requirements are.
What should an NP do if she/he
has a number, is billing properly, but is not getting
paid?
It is common for payors to reject claims from all
types of providers for various reasons, including incomplete
claims, inaccurate information, non-covered services,
and other errors. Therefore, the NP must get involved
by calling the third party payor directly and resolving
the issue. Direct involvement will help the NP develop
a better understanding of the reimbursement process
and covered benefits.
What are ICD-9-CM codes?
ICD-9-CM is the acronym for the 9th revision of the
international classification of diseases, impairments,
injuries, symptoms and causes of death. These codes
are the universal classification system for all clinical
documentation. All claims for services provided include
an ICD-9-CM code. The ICD-9-CM manuals are available
for purchase through the American Medical Association.
What are CPT codes?
Physicians' Current Procedural Terminology (CPT) is
a systematic listing and coding of all procedures and
services performed by practitioners. Every service or
procedure is identified by a specific five-digit code.
This coding system accurately identifies all services
or procedures, simplifies reporting, and is very useful
for billing and reimbursement. Evaluation and Management
(E&M) CPT codes (99201-99499), which include office
visits, are the most used.
CPT codes may have a professional component and a
technical component. For instance, with radiology CPT
codes, the professional component is the portion identifying
the radiologist's service (e.g. interpretation of a
chest x-ray), and the technical portion is the actual
x-ray. There is an approved fee for each portion (professional
and technical) of the service, and if the two parts
are combined into one fee, it is called a global fee.
All claims for services provided must include a CPT
code. The CPT manuals are available for purchase through
the American Medical Association.
What is a facility charge?
Some services may have an associated facility charge.
Usually such charges are associated with hospitals,
ambulatory surgery centers and some clinics. In general,
a facility charge is associated with a procedure, not
with an office visit. Examples of situations where facility
charges may be billed are emergency department services,
outpatient surgeries and outpatient/ambulatory care
procedures. Urgent care/walk-in care centers do not
bill facility charges because the type of services provided
in these settings analogous to office visits.
What is "compliance"?
Practices are regularly audited by third party payors
for compliance with their requirements for appropriate
documentation and coding. Lack of compliance can result
in heavy fines and charges of fraud. Therefore it is
important for all practitioners to have knowledge of
reimbursement and to particularly understand payors'
requirements for reimbursement. Read provider manuals,
call the payors directly and ask lots of questions.
Why is it important for NPs
to have and use their own provider numbers?
NPs who have their own provider number are "visible"
in the health care system. Billing under the physician
number prohibits the collection of data concerning the
work NPs do and physicians often get credit for NP productivity.
The costs for a practice are increased if the physician
must see each new patient. The NP can very easily and
cost effectively see new patients. If the NP has a provider
number the physician does not have to be on site, and
the physician can go to other sites/leave the office.
What strategies could be used when an NP is trying
to convince the office that she/he should obtain and
use her/his own provider number for billing?
Do the math - 15% of an office visit is not that much
in the overall picture.
Calculate the income the physician could earn if he/she
is able to be off site seeing patients at other facilities.
Calculate the savings that result from the physician
not having to see all new patients. If NPs have their
own provider number, it will help avoid situations which
could be fraudulent. The scare of an audit and having
to repay Medicare and additionally pay a large fine
is enough to balance the loss of 15%.
How can I obtain applications
for provider numbers?
Blue Cross/Blue Shield - CNP/CNM Credentialing - Mail
Code B444; Blue Cross Blue Shield of Michigan; 600 E.
Lafayette Blvd.; Detroit, MI 48226-2998; Phone 800/985-7434.
Medicaid - Provider Enrollment; Medical Services Administration;
P.O. Box 30238; Lansing, MI 48909-7979. Providers may
phone 517/335-5492.
Medicare - Medicare Part B; Michigan Inquiries; P.O.
Box 5533; Marion, IL 62959; hone 877/567-7201. Medicare
keeps on file a copy of your current RN license &
NP State of Michigan certification. Send current copies
when you renew your license & certification every
two years.
Do NPs need a collaborative agreement
or any other type of written agreement with physicians?
A collaborative agreement with a physician is required
for Michigan nurse practitioners to receive direct Medicaid
and Medicare reimbursement. It may be required for other
third party payors, such as managed care organizations,
and therefore the NP should be aware of those requirements
when applying for provider status with other payors.
BC/BS of MI does not require an agreement for NPs but
does require one for certified nurse midwives.
Nursing practice as defined by MI law is not dependent
upon physician delegation or supervision, and it is
not a subset of medical practice. Nursing is an independent
profession. Delegation or supervision does not apply
for those acts performed within the nurse's scope of
practice. The definition of nursing - the scope of practice
- is provided in the Public Health Code; it is the same
for all nurses, generic RNs and NPs. Those elements
of a nurse practitioner's practice which fall within
this definition/scope and for which the NP is prepared
educationally and experientially constitute the practice
of nursing. They do not need to be delegated. All NPs
should be clear about what their scope of nursing practice
is.
Collaborative agreements, which define the relationship
of NPs working with physicians to deliver health care
services, need to be carefully written and should not
state that a physician is delegating or supervising
when not required or not appropriate.
Medicaid stipulates in the most detail what a collaborative
agreement must include. Medicare requires that there
must be a written agreement in place. Therefore, if
NPs create and implement collaborative agreements which
comply with Medicaid requirements, the agreement will
likely be satisfactory to other payors, including Medicare.
Prescriptive authority may be delegated to an NP by
a physician. Delegation of non-controlled substances
does not require a written document. However, delegation
of Schedule 2, 3, 4 & 5 drugs does require written
authorization of the delegation.
Following is an explanation of elements for a collaborative
agreement and for delegation of prescription of controlled
substances, as well as some sample documents. The sample
documents are merely for example. All NPs should write
agreements as appropriate to their individual practices
(and in accordance with legal regulations).
KEY
ELEMENTS IN A COLLABORATIVE AGREEMENT |
| Element |
Required by |
| A written agreement is available
for review upon request |
Medicaid, Medicare |
| 1. A. Description of the kinds
of services to be provided Examples - management
of chronic, stable illness & acute episodic
illness; health maintenance services |
Medicaid |
| 1. B. Criteria for referrals
and consultations Example - identify protocols
or texts used for decision-making for referrals
and consultations |
Medicaid |
| 2. Mutual development by,
or approval as satisfactory to, both the NP
and physician Both parties should sign, date
and review periodically |
Medicaid |
| 3. Systematic formal planning
and evaluation meetings occur between the NP
and physician Example - Include schedules/times
for consultation between the two, to review
records and/or provide telephone consultation.
Could show that both parties review practice
protocols and appropriately sign and date |
Medicaid |
| 4. Periodic formal reports
(oral or written), which assess the implementation
of the collaborative practice arrangement, progress
toward established objectives and outcomes,
are made Objectives and outcomes are not necessarily
written, but reflect the mutual goals of the
practice agreement. Formal reports focus on
quality assurance. |
Medicaid |
| 5. Documented evidence of
consultation as needed between the NP and physician
Examples - Progress note, countersignature of
physician, use of "consultation form," chart
note, copy of letter requesting consult. |
Medicaid |
| 6. Recognition of limits of
statutory and clinical authority and accountability
in relations to established goals and needs
of clients. Include a statement in the agreement
which acknowledges mutual understanding of the
separate accountability of each professional
for his/her scope of practice. |
Medicaid |
| Delegation of prescriptive
authority for controlled substances in Schedules
2-5 requires a written authorization of such
delegation. The written authorization should
contain the signatures and license numbers of
both parties. A signed authorization must be
at each practice site. Exceptions and limitations,
if any, must be noted. The effective date must
be included. The authorization must be reviewed
(updated if needed) annually. Note: Schedule
2 drugs may only be delegated if the NP and
physician are practicing within a hospital,
freestanding surgical OP facility or hospice.
|
Prescriptive Authority |
Recommendations for the Process to Develop a Collaborative
Agreement
- Parties to the collaborative practice agreement
should engage in ongoing communication - face-to-face
is encouraged
- Regularly scheduled formal exchanges aimed at
mutual planning, problem solving and evaluation
of the collaborative practice model, how it is
working, outcomes, etc. are recommended.
- Ongoing dialogue of relevant information, progress
toward goals, assessment of data and discussion
of joint problem solving efforts is recommended
- Each professional who is party to the collaborative
practice agreement is responsible and accountable
for performing to the full and appropriate extent
his/her role and function, level of knowledge and
expertise, legal practice regulations and practice
environment policies dictate.
- Parties to the collaborative practice agreement
explicitly plan and systematically evaluate their
autonomous and overlapping roles and functions in
relation to mutually established goals.
- Mutual formulation of goals, plans, decisions
when appropriate
- Demonstration of mutual trust, respect and contributions
in a collegial manner
- Demonstration of consultation when appropriate,
and the availability for consultation
- Clear articulation of knowledge and skills of
the parties in the collaborative agreement
- Demonstration of the contributions of each
collaborator toward the mutually established goals.
Collaborative
Agreement Sample A
Collaborative
Agreement Sample B
Collaborative
Agreement Sample C
Collaborative
Agreement Sample D
Collaborative
Agreement Sample E
Model
for Prescriptive Authority - Delegation of Controled
Substances
ANNOTATED
BIBLIOGRAPHY
Center for Medicare/Medicaid Services
The Health Care Financing Administration (HCFA) has
a new name - Center for Medicare/Medicaid Services (CMS).
This organization has a wealth of information needed
by nurse practitioners who do documentation for evaluation
and management and identify coding for those services.
Click on their website http://www.HCGA.gov/medicare/mcarpti.htm.
The website that reflects the organization's new name
is under development.
American Nurses Association
An excellent resource to assist with reimbursement questions
is Understanding Payment for Advanced Practice Nursing
Services. Written by Shelia Abood and David Keepnews,
this ANA publication is available for purchase from
American Nurses Publishing phone 800-637-0323.
- Richmond, T.S., Thompson, H.J., & Sullivan-Marx,
E. (2000, January). Reimbursement for Acute Care Nurse
Practitioner Services. American Journal of Critical
Care, volume 9. pps 32 - 38, 59-61.
This is one of the best articles describing the repercussions
of he 1997 Balanced Budget Act on reimbursement to acute
care nurse practitioners. It gives reasons for which
the ACNP must be responsible for knowing how to implement
billing mechanisms to take full advantage of the new
regulations, gives a full description of incident -
to Medicare B billing constraints and the changes resulting
from the ability of the APN to obtain direct reimbursement
from Medicare. A full definition of the concept of collaboration
by the Health Care Financing Administration (HCFA) rules
and regulations is included. Gives case histories and
billing practice procedures of some common occurrences
in hospital ER's, in-patient services. Also describes
reimbursement practices for outpatient settings. Answers
the important questions - How to get a Medicare provider
number, who can submit bills for Medicare reimbursement,
what can be charged, where to get this information,
and answers how to determine the amount of reimbursement.
- ICD-9CM Easy Coder (1999). Montgomery, AL: Unicor
Medical, Inc.
All diagnoses are listed alphabetically; find the
diagnosis by looking alphabetically for the key word,
the anatomical site, or the first word in the diagnosis
description. Learning the diagnostic codes or how to
find them ensures that the correct codes are used and
that the correct level of care can be charged; better
to enhance practice revenues. To order call 1-800-825-7421.
- Nursing's Social Policy Statement. (1995). Washington,
D.C.: American Nurses Association.
The members of the nursing profession should understand
the framework for nursing's relationship with society
and nursing's obligation to those who receive nursing
care.
Nursing's Social Policy Statements include a description
of nursing in the United States - the values and social
responsibility of the profession, nursing's definition
and scope of practice, nursing's knowledge base, and
the methods by which nursing is regulated. The statement
is both an accounting of nursing's professional stewardship
and an expression of nursing's continuing commitment
to the society it serves. To order call 800/637-0323.
- Credentialing & Privileging of Advanced Practice
Nurses. (1997). Okemos, MI: Michigan Nurses Association.
A document written by the Marketing Coalition of the
Michigan Nurses Association's Advance Practice Council
to be used as a reference for advanced practice nurses
and health care facilities, to provide guidelines for
developing criteria for credentialing and privileging.
It is neither mandatory nor all-inclusive, and the working
may be altered to adapt to particular circumstances,
specific providers and individual institutions. A brief
walk through the process and requirements for institutional
credentialing and privileging of advanced practice nurses
is concise and to the point.
A sample job description is included with principle
duties and responsibilities outlined.
- Buppert, Carolyn. (1999). Nurse Practitioner's Business
Practice & Legal Guide. Gaithersburg, Maryland:
Aspen Publishers, Inc.
This book is one of the most helpful resources a practicing
nurse practitioner can have at her fingertips to answer
legal practice questions. Written by a nurse practitioner
who is also an attorney, the book contains the answers
to most of the questions and issues faced in general
practice. Topics include:
- Definitions of a Nurse Practitioner, including state-by-state
definitions
- Legal scope of Nurse Practitioner Practice, including
state-by-state definitions
- State regulation of Nurse Practitioner Practice
- Federal Regulation of the Nurse Practitioner Profession
- Prescriptive privileges including a state-by-state
description of regulations
- Hospital Privileges
- Negligence and Malpractice
- Risk Management
- Reimbursement Issues for Nurse Practitioner Services
- Practice Ownership Issues
- Lawmaking and Health Policy
- Promotion of the Profession to the Public
- Standards of Care for Nurse Practitioner Practice
- Measurement Nurse Practitioner Performance
- Strategies for Advancement of the Profession
To order this book - 800-638-8437
- Buppert, Carolyn. (2000). The Primary Care Provider's
Guide to Compensation and Quality: How to Get Paid
& Not Get Sued. Gaithersburg, Maryland: Aspen
Publishers, Inc.
The author of this book is both an advanced practice
nurse and an attorney. In this reference, she answers
questions that have been posed to her by primary care
providers. The book includes information about how to
maximize reimbursement while complying with federal
coding and billing guidelines. It also addresses issues
related to quality audits, strategies to avoid malpractice,
how to monitor and improve medical outcomes at the practice
level and how to save time while doing it all. Sample
documentation forms are provided in the appendix and
also on computer diskette.
- Occupational Regulation Section of the Michigan
Public Health Code and Michigan Board of Nursing Administrative
Rules. (1999). Lansing, MI: Michigan Department of
Consumer & Industry Services.
These documents contain statutes and rules that regulate
health care professionals in Michigan. The schedules
for controlled substances are included.
To request a copy of each write to:
Michigan Department of Consumer and Industry Services
Office of Health Services
P.O. Box 30670
Lansing, MI 48909-8170
Resources
Journals
- The Nurse Practitioner
- Journal of the American Academy of Nurse Practitioners
- Advance for Nurse Practitioners
- Journal of Nursing Scholarship, formerly Image:
Journal of Nursing Scholarship
- American Journal of Nursing
- Patient Care for the Nurse Practitioner
- The Clinical Advisor for Nurse Practitioners
Websites
Telephone Numbers
- Michigan Nurses Association - 888-646-8773
- American Nurses Association - 202/554-4444
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