CRNAs, NPs and PAs: What You Must Know About Scope of Practice, Supervision and Delegation

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CRNAs, NPs and PAs What You Must Know About
Scope of Practice, Supervision and Delegation

• MHA Health Foundation
• Winter Leadership Conference
• February 15, 2007
• Joan L. Lowes, Esq.
• [phone]
• jlowes_at_hallrender.com

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• Todays Topics
• Qualifications, Scope of Practice, Supervision
  and Delegation
• Protocols, Employment and Contracting
• Coverage and Reimbursement
• Practical Tips
• Legislative Update

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Qualifications
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Qualifications for Certified Registered Nurse
Anesthetist (CRNA)

• A Certified Registered Nurse Anesthetist is a
  registered nurse who is licensed by the state in
  which the nurse practices and who
• Is currently certified by the Council on
  Certification of Nurse Anesthetists or the
  Council on Recertification of Nurse Anesthetists,
  or
• Has graduated within the past 18 months from a
  nurse anesthesia program that meets the standards
  of the Council of Accreditation of Nurse
  Anesthesia Educational Programs and is awaiting
  initial certification

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Qualifications for Nurse Practitioners (NPs)

• The professional services of an NP may be covered
  under Medicare part B if he or she meets the
  qualifications listed below and is legally
  authorized to furnish services in the state where
  the services are performed.
• To qualify for Medicare Part B coverage of his or
  her services, an NP must
• Be a registered professional nurse authorized by
  the state in which the services are furnished to
  practice as an NP in accordance with state law,
  and
• Be certified as a nurse practitioner by a
  recognized national certifying body that has
  established standards for nurse practitioners or
• Have been granted a Medicare billing number as an
  NP by December 31, 2000.
• NPs who applied for a Medicare billing number for
  the first time from January 1, 2001, through
  December 31, 2002 must meet the requirements as
  follows
• Be a registered nurse authorized by the state in
  which the services are furnished to practice as
  an NP in accordance with state law and
• Be certified as an NP by a recognized national
  certifying body that has established standards
  for NPs.

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Qualifications for Nurse Practitioners (NPs)
Contd

• NPs who apply for a Medicare billing number for
  the first time on or after January 1, 2003, must
  meet the requirements as follows
• Be a registered professional nurse who is
  authorized by the state in which the services are
  furnished to practice as an NP in accordance with
  state law
• Be certified as an NP by a recognized national
  certifying body that has established standards
  for NPs and
• Possess a Masters degree in nursing

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Certifying Organizations for Nurse Practitioners
(NPs)

• The following organizations are recognized
  national certifying organizations for NPs
• American Academy of Nurse Practitioners
• American Nurses Credentialing Center
• National Certification Corporation for Obstetric,
  Gynecologic and Neonatal Nursing Specialties
• National Certification Board of Pediatric Nurse
  Practitioners and Nurses
• Oncology Nurses Certification Corporation and
• Critical Care Certification Corporation

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Qualifications for Physician Assistants

• In order to furnish Medicare Part B covered
  services, the PA must meet the following
  conditions
• Have graduated from a physician assistant
  educational program that is accredited by the
  Accreditation Review Commission on Education for
  the Physician Assistant (its predecessor
  agencies, the Commission on Accreditation of
  Allied Health Education Programs (CAAHEP)) and
  the Committee on Allied Health Education and
  Accreditation (CAHEA) or
• Have passed the national certification
  examination that is administered by the National
  Commission on Certification of Physician
  Assistants (NCCPA)
• Be licensed by the state to practice as a
  physician assistant

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Scope of Practice
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NP Scope of Practice

• Practice of nursing defined broadly under State
  Law
• Nurses licensed to practice independently
  consistent with their education and experience

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NP Scope of Practice (Contd)

• Nurse specialty certifications (CRNAs, certified
  nurse midwives and nurse practitioners)
• No delineated scope of practice for specialists,
  defined by general nursing scope of practice and
  advanced education and training

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CRNA Scope of Practice

• In Michigan,
• Anesthesia practice of medicine
• Therefore, the
• Practice of anesthesia by CRNA is by delegation
  and under supervision of a physician

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PA Scope of Practice

• Defined by State law, as subfield of practice of
  medicine, osteopathic medicine and podiatric
  medicine and surgery
• Except in emergency, practice under physician
  supervision and delegation
• May perform any services within scope of practice
  of physician (except tests to determine
  refractive state of eye and lens prescribing)
  provided PA has requisite education, training and
  skills

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Supervision and Delegation
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Supervision in Michigan 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 review
  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 individuals functions.
• The provision by the licensed supervising health
  professional of predetermined procedures and drug
  protocol.

MCL 333.16109
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Delegation in Michigan means

• Delegation to a licensed or unlicensed individual
  who is otherwise qualified by education, training
  or experience the performance of selected acts,
  tasks or functions where the acts, tasks or
  functions fall within the scope of practice of
  the licensees profession and will be performed
  under the licensees supervision
• A licensee shall not delegate an act, task or
  function under this section if the act, task or
  function, under standards of acceptable and
  prevailing practice, requires the level of
  education, skill and judgment required of the
  licensee under this article.

MCL 333.16104 333.16215
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Supervision and Delegation - CRNAs

• State law rules on supervision and delegation
  apply
• Caveat Medicare Conditions of Participation
  further define supervision

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Supervision and Delegation - CRNAs

• COPs require CRNA to be supervised either by
  operating practitioner or anesthesiologist who is
  immediately available
• Immediately available means
• In the OR
• Prepared to immediately intervene
• Not engaged in activities that would prevent
  immediate intervention

42 CFR 482.52
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Supervision and Delegation - PAs

• Under Michigan law, physician must
• Verify credentials
• Evaluate performance
• Monitor practice
• Maintain record of name and license number of
  each supervisee
• Supervise no more than 4 PAs
• Establish written drug protocols

MCL 333.17049
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Supervision and Delegation - NPs

• No special statutory requirement of supervision
  as with PA
• General definitions of supervision and delegation
  apply
• Caveat subject to collaboration requirements
  of Medicare and Medicaid which call for medical
  direction and supervision

42 CFR 410.75
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Protocols, Employment and Contracting
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Collaboration
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Collaboration

• Collaboration is a process in which
• An NP works with one or more physicians (MD/DO)
  with medical direction and appropriate
  supervision (as required by law of the state in
  which services are furnished)
• An NP delivers health care services (within the
  scope of the NPs professional expertise)
• In the absence of state law governing
  collaboration, collaboration is to be evidenced
  by the NP documenting his or her scope of
  practice and indicating the relationships that
  the NP has with physicians to deal with issues
  outside the NPs scope of practice.
• Note The collaborating physician does not need
  to be present with the CNS when the services are
  furnished or to make an independent evaluation of
  each patient who is seen by the CNS.

42 CFR 410.75
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Collaborative Relationship Entails

• Systematic formal planning meetings
• Periodic formal reports assess implementation of
  collaboration agreement, progress and outcomes
• Documented evidence of consultation as needed
• Recognition of limits of authority and
  accountability

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Collaborative Relationship Entails (Contd)

• Written agreement between the NP and physician
• Agreement should define parameters of nurses
  abilities and responsibilities, criteria for
  referral and consultation
• Medicaid form agreement (DCH-1575)

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Controlled Substances
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PAs and NPs only

• Delegated authority for schedules III-V (II in
  facilities only)
• Requires signed authorization with name, license
  , effective date any limitations
• Review update authorizations annually and keep
  at each practice location
• Must obtain own DEA registration
• Prescription must include name of delegating
  physician with DEA and PA or NP DEA

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Alternative Employment Structures
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Alternative Structures for Employing Mid-Levels

• Option 1 Physician Practice employ mid-levels
  full-time
• Option 2 Hospital employs mid-levels and leases
  them to Physician Practice (or vice versa)
• Option 3 Hospital and Physician Practice each
  separately employ mid-levels part-time

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Option 1 Physician Practice Employs Mid-Levels
Full-Time

• The cleanest and simplest model
• Works well for practices that need full-time
  mid-level support
• Full-time employment generally preferred by
  mid-levels

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Option 1 (Contd)

• Works well in office setting where mid-levels can
  bill incident to and receive highest
  reimbursement
• In hospital setting, Practice may bill for
  mid-levels professional services
• In either setting, Practice can bill for
  split/shared EM services

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Option 2 Hospital Employs Mid-Levels and then
Leases to Practice (or vice versa)

• Works well for Practices that do not have the
  need or means to employ full-time
• Same supervision/billing/reimbursement rules
  apply as under employment arrangement

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Option 2 (Contd)

• Other considerations
• For PAs, need to structure lease agreement to
  satisfy requirement that practice is the
  employer for purposes of billing. Contract
  terms should include
• Practice retains control while PAs are working
  for the Practice
• Practice is paying prorated share of salaries,
  fringes and employment taxes
• Practice retains the right to remove a PA from
  the leasing arrangement, for cause.

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Option 2 (Contd)

• Other considerations
• Compensation must be fair market value based on
  FTE designation
• Base on compensation benefits paid by employer
• Use set schedule
• Use time studies
• Use daily/weekly timesheets
• Implement monitoring/review mechanism

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Option 3 Hospital and Practice Each Separately
Employ Mid-Levels Part-Time

• Works well for practices who do not need or
  cannot afford full-time mid-level support
• Each employer retains greatest degree of control
  over its workers
• Less complicated and administratively burdensome
  than lease arrangement

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Option 3 (Contd)

• Less risky because no need to ensure Practice is
  PAs employer for billing purposes
• Less risky because no need to ensure fair market
  value, accurate time studies, etc.
• Less attractive to mid-levels who want full-time
  benefits somewhere

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Coverage and Reimbursement
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CRNA
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Covered Services

• Payment for the services of a CRNA may be made to
  the CRNA who furnished the anesthesia services or
  to a hospital, an Ambulatory Surgical Center
  (ASC), or an anesthesiologist with which the CRNA
  has an employment or contractual relationship.

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Medicare

• With medical direction 50/50
• Without medical directions payment to CRNA at
  lower of charges, MD fee schedule or CRNA fee
  schedule amount

42 CFR 414.46
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Medical Direction means that physician

• Performs pre-anesthetic exam and evaluation
• Prescribes anesthesia plan
• Personally participates in most demanding
  procedures, including induction and emergence
• Ensures that any procedures he or she does not
  perform are performed by a qualified
  anesthesiologist
• Monitors the course of anesthesia at frequent
  intervals
• Remains physically present and available for
  immediate diagnosis and treatment of emergencies
• Provides indicated post-anesthesia care

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Rural Hospitals

• Pass-through exemption for CRNAs
• Method II Option can retain or give up exemption

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Medicaid

• Same as Medicare

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Blue Cross

• Medical direction (40)
• Non-medical direction (85)

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PA / NP
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Coverage -- Medicare

• Services otherwise covered if furnished by a
  physician
• All levels of EM services, diagnostic and
  therapeutic procedures
• Consults
• Services and supplies incident to

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Reimbursement -- Medicare

• Services reimbursed in all settings and as
  assistant at surgery
• If services furnished independently, bill under
  mid-levels provider number

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Reimbursement Medicare (Contd)

• Payment made only to PAs employer, not PA, at
  85 of schedule amount
• NP reimbursement at 85 of physician fee
  schedule, paid to NP if services independently

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Reimbursement Medicare (Contd)

• May furnish services incident to services of a
  physician in office or clinic, not hospital
• All requirements of incident to rule must be
  met
• Service must be integral, though incidental, part
  of physicians services
• Each incidental service does not require separate
  physician service but physician must be on
  premises and immediately available

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Reimbursement Medicare (Contd)

• Physician must have initiated course of treatment
  and must have continuing services of frequency to
  indicate active participation and management of
  patient
• PA/NP must be part of same group or have same
  employer as physician
• Incident to services are billed under
  physicians PIN and paid at fee schedule amount

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Reimbursement Medicare (Contd)

• Split/shared visits
• Any setting
• Physician and mid-level each perform portion of
  face-to-face encounter
• May bill under either PIN
• Must be part of same group or have same employer

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Reimbursement -- Medicaid

• PA reimbursed under supervising physicians PIN
• NP may enroll and be reimbursed under his/her PIN
  or supervising physicians PIN

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Reimbursement Blue Cross

• PAs reimbursed under supervising physicians PIN
• NP may enroll and be reimbursed under his/her PIN
  at the lesser of charges or 85 of the physician
  fee schedule

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Physician Co-Signature Requirements

• Independent visits
• Split/shared visits
• Incident to
• Hospital HPs

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Resources for CRNA

• Medicare Claims Processing Manual, Chapter 12,
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• Wisconsin Physician Services, Policy AN-001
• Medicaid Provider Manual, Practitioner,
• 2, 21

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Resources for PA

• Medicare Claims Processing Manual, Chapter 12,
  110
• Medicare Benefit Policy Manual, Chapter 15, 190
• Wisconsin Physician Services, Policy PHYS-026

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Resources for NP

• Medicare Claims Processing Manual, Chapter 12,
  120
• Medicare Benefit Policy Manual, Chapter 15, 180
• Wisconsin Physician Services, Policy PHYS-034

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