Nurse Practitioner FAQ's
About the Michigan Nurses Association
Introduction and Purpose
Accessing Michigan Laws and Administration Rules
Limitations on Practice
Scope of Practice
Application of Standards to Nursing Practice
Countersignatures of Collaborating Physicians
Credentialing and Privileging
Giving Orders to RNs
Long Term Care
Quality Care Improvement Projects
Third Party Payors
Billing Criteria for NP Reimbursement
Direct Reimbursement from Medicare
Indirect Reimbursement (Incident to) from Medicare
Application for Provider Number
Collaborative Agreement with Physicians
This document was originally 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. Information regarding rules, regulations and reimbursement changes frequently. The reader is advised to ensure that all such information pertaining to practice is current and updated to March 2012.
The Michigan Nurses Association is the largest, most effective union for RNs in Michigan. As the voice of all registered nurses in Michigan, MNA advocates for nurses and their patients at the State Capitol, in the community and at the bargaining table. MNA is an affiliate of National Nurses United and the AFL-CIO.
As the number of Advanced Practice Registered Nurses (APRNs) completing their education increases, so does the number of questions relating to APRN 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 APRN 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 (NPs). 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.
There are a number of references in this publication to Michigan laws and rules, To access this information, go to www.michigan.gov/healthlicense, and click “nursing” from the left side of the page. This will take you to the Michigan Board of Nursing web site, where you will find a variety of links to a variety of information, including the Board’s administrative rules.
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 an APRN the registered nurse may not "hold herself/himself out to the public" (see R338.10403) as an APRN. Without Michigan Board of Nursing certification you cannot obtain a provider number for Medicaid, Blue Cross or Medicare, or for any other third party reimbursement (Medicare makes certain exceptions for clinical nurse specialists).
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 APRN program you have completed enlarges your scope and enables you to practice using the knowledge, skill and judgment you learned in the program.
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:
R 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 (R 338.10401-10406): R 338.10403 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.)
A specialty certification for nurse practitioner can be granted to a registered nurse that satisfies the requirements stated under Certification qualifications; nurse anesthetist, nurse midwife, and nurse practitioner (R 388.10404): holds a current and valid license to practice nursing in Michigan, meets the advanced practice certification standards of one of the following organizations: The American Nurses Credentialing Center, The National Certification Board of Pediatric Nurse Practitioners and Nurses, Inc., The National Certification Corporation for Obstetric, 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 Department of Community Health, Bureau of Health Professions; visit 6611 W. Ottawa St., 1st Floor, Lansing, MI 48933, write to P.O. Box 30670; Lansing, MI 48909, or visit the web site www.michigan.gov/healthlicense (click “nursing” from the left side of the page, and view the link for nurse specialty certification).
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.
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 yet delineate by law a scope of practice specific to APRNs. All nurses are responsible and accountable for recognizing the limits of their knowledge and skill.
In the state of Michigan, APRNs 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 APRNs, the role he/she is in, and the client population within the practice environment. The American Nurses Association has developed two publications to assist APRNs 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 APRNs. The following are generic functions applicable to many APRN 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
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 the American Nurses Association's Scope and Standards of Advanced Practice Registered Nursing, developed by the ANA 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.
The ANA's standards of practice include: assessment, diagnosis, outcomes identification, planning, implementation, coordination of care, health teaching and health promotion, consultation, prescriptive authority and treatment, and evaluation.
Section R 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 the 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.
Section R 333.16215 of the Public Health Code is not determinative in deciding whether nurses are "supervisors" as defined by the National Labor Relations Act (NLRA).
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 physician assistants (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 APRNs. 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 the 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 an APRN?
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.
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 APRN 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 APRN or physician with clinical privileges at the institution of application, job description/ outline of specific clinical services to be provided by the APRN, health clearance release form, malpractice coverage policy, recent BCLS/ACLS certification.
Clinical Privileging: An entitlement process whereby an APRN 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 APRN 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 APRN is qualified may be listed.
A common situation where APRNs might write orders that would be directed to other RNs for implementation is in a hospital. Usually the hospital has a system for privileging APRNs and it is clear as to what the APRN may order both as independent nursing orders and as physician delegated medical activities.
As we know, nurses do not have legal authority to prescribe/order medications. However, they may prescribe as a delegated function from a physician. If an APRN writes an order for medication, the name of the delegating physician must be included on the order. An RN (non-APRN) may accept an order written in this fashion.
When an APRN 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 APRNs to write orders. Anything ordered by an APRN, under the APRN's name alone (no physician name), must fall within the scope of practice of the APRN.
State and Federal guidelines regarding the delegation of tasks to NPs in the long-term care setting can be found in the State Operations Manual Appendix PP - 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, AHCA Publications and their address is 1201 L Street, N.W., 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.
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 http://www.thecmafoundation.org/projects/aped/.
- 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 (MPRO) 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.cms.gov/ or http://www.mpro.org/.
Websites for quality improvement
Michigan Peer Review Organization - http://www.mpro.org/
National Committee for Quality/HEDIS Assurance - http://www.ncqa.org/
Agency for Health Research and Quality - http://www.ahcpr.gov/
The Joint Commission - http://www.jointcommission.org/
Best Practice Network - http://www.best4health.org/
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 APRN services:
- Direct, with the APRN’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).
In Michigan, the following payors provide reimbursement to APRNs:
Medicaid - recognizes APRNs and provides direct reimbursement
Medicare Secondary ("Gap") Payors - Many commercial insurances recognize APRNs, as Medicare does, and provide direct reimbursement
Federal Insurances - Champus, BC/BS Federal and Railroad Medicare recognize APRNs and provide direct reimbursement
Blue Cross/Blue Shield of Michigan - recognizes APRNs and provides direct reimbursement
Commercial Insurances & Traditional Indemnity Plans - Although it varies among companies, many recognize APRNs and provide direct reimbursement
HMOs - Many of the HMOs that provide Medicaid services will allow APRNs to have provider status and receive direct reimbursement. However, many of the HMOs licensed for commercial business do not allow APRNs to be on their provider panels. Therefore, it is important to inquire of each HMO what its policies are. Typically, reimbursement for services provided by APRNs is obtained indirectly, under the physician's name and number.
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 APRNs. Third party payors vary substantially; therefore, it is critical that all APRNs 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.
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 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 APRN's name and APRN'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."
Medicare calls billing and receiving payment under a physician's name for services provided by an APRN "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 APRN renders the service;
- Was provided by an APRN 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 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 non-physician 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 APRN.
As of July 2001, CMS, 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 for Michigan may require additional criteria, such as the physician seeing the patient for each new problem.
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.
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 APRN must get involved by calling the third party payor directly and resolving the issue. Direct involvement will help the APRN develop a better understanding of the reimbursement process and covered benefits.
ICD-10-CM is the acronym for the 10th 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-10-CM code. The ICD-10-CM manuals are available for purchase through the American Medical Association.
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.
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.
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.
APRNs 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 APRNs do and physicians often get credit for APRN productivity. The costs for a practice are increased if the physician must see each new patient. The APRN can very easily and cost effectively see new patients. If the APRN 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 APRN 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 APRNs 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%.
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) 482-3600.
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 62959-0965; phone (877) 567-7201. Medicare keeps on file a copy of your current RN license & APRN State of Michigan certification. Send current copies when you renew your license & certification every two years.
A collaborative agreement with a physician is required for Michigan APRNs to receive direct Medicaid and Medicare reimbursement. It may be required for other third party payors, such as managed care organizations, and therefore the APRN should be aware of those requirements when applying for provider status with other payors.
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 APRNs. Those elements of a APRN’s practice which fall within this definition/scope and for which the APRN is prepared educationally and experientially constitute the practice of nursing. They do not need to be delegated.
Collaborative agreements, which define the relationship of APRNs 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 APRNs 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 APRN 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 APRNs should write agreements as appropriate to their individual practices (and in accordance with legal regulations).
KEY ELEMENTS IN A COLLABORATIVE AGREEMENT
A written agreement is available for review upon request.
1. A. Description of the kinds of services to be provided. Examples - management of chronic, stable illness & acute episodic illness; health maintenance services.
1. B. Criteria for referrals and consultations. Example - identify protocols or texts used for decision-making for referrals and consultations.
2. Mutual development by, or approval as satisfactory to, both the APRN and physician. Both parties should sign, date and review periodically
3. Systematic formal planning and evaluation meetings occur between the APRN 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.
4. Periodic formal reports (oral or written) are made which assess the implementation of the collaborative practice arrangement and progress toward established objectives and outcomes. Objectives and outcomes are not necessarily written, but reflect the mutual goals of the practice agreement. Formal reports focus on quality assurance.
5. Documented evidence of consultation as needed between the APRN and physician. Examples - Progress note, countersignature of physician, use of "consultation form," chart note, copy of letter requesting consult.
6. Recognition of limits of statutory and clinical authority and accountability in relation 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.
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.
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 that 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.
Center for Medicare/Medicaid Services
The Center for Medicare/Medicaid Services (CMS) has a wealth of information needed by APRNs who do documentation for evaluation and management and identify coding for those services. Click on their website http://www.cms.gov.
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. pages 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-10-CM Easy Coder (2012). 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.
Buppert, Carolyn. (1999). Nurse Practitioner's Business Practice & Legal Guide, Fourth Edition. 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
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. (2008). Lansing, MI: Michigan Department of Community Health. These documents contain statutes and rules that regulate health care professionals in Michigan. The schedules for controlled substances are included. Visit the Michigan Board of Nursing web site by going to www.michigan.gov/healthlicense, clicking “nursing” from the left side of the page, and look for the links to go to the Occupational Regulation Section and to the Administrative Rules
Nurse Practitioner's Guide to Evaluation & Management Coding (revised edition). St. Paul, MN: Medical Learning, Inc.
This reference provides a basic overview of CPT (Current Procedural Terminology) coding and E&M (Evaluation and Management) coding. There is also a review of the Balanced Budget Act provisions that affected nurse practitioners’ services and changed the method of payment. Overall, it provides an explanation of how to code correctly and document sufficiently to support the codes chosen. To order write 287 6th St E # 400 Saint Paul, MN 55101, or call
- The Nurse Practitioner
- Journal of the American Academy of Nurse Practitioners
- Advance for Nurse Practitioners
- Journal of Nursing Scholarship
- American Journal of Nursing
- Patient Care for the Nurse Practitioner
- The Clinical Advisor for Nurse Practitioners
- The Nurse Practitioner
- Journal of the American Academy of Nurse Practitioners
- Advance for Nurse Practitioners
- Journal of Nursing Scholarship
- American Journal of Nursing
- Patient Care for the Nurse Practitioner
- The Clinical Advisor for Nurse Practitice