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CMS rule creates reimbursement opportunities for RNs

Thursday November 15, 2012
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The American Nurses Association touted a new Medicare rule that calls for paying advanced practice RNs for primary care services intended to effectively manage patientsí transitions from hospitals to other settings while preventing complications and conditions that lead to expensive hospital readmissions.

The rule also creates new payment codes for care coordination activities performed by RNs that reduce costs and improve patient outcomes, increasing the likelihood of direct reimbursement for these services and potentially creating more RN jobs to fill this need. (For more information, see the PDF at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2013-Medicare-Physician-Fee-Schedule-Final-Rule.pdf and go to page 282 for the section on transitional care.)

With up to 20% of Medicare patients readmitted to hospitals within 30 days of discharge, more value has been placed on effective transitional care and care coordination. "The American Nurses Association has been advocating for years that government and private insurers need to recognize nursesí contributions to transitional care and care coordination and pay appropriately for these essential services," ANA President Karen A. Daley, RN, PhD, MPH, FAAN, said in a news release. "This Medicare rule is a giant step forward for nurses whose knowledge and skills play major roles in patientsí satisfaction and quality of care."

The ANAís 2012 report, "The Value of Nursing Care Coordination" (www.nursingworld.org/carecoordinationwhitepaper), highlighted numerous studies showing the positive impact of nurse-managed care coordination. Studies have showed that care coordination reduces ED visits, hospital readmissions and medication costs; lowers total annual Medicare costs; improves patient satisfaction and confidence to self-manage care; and increases safety for older adults during transitions between settings.

The ANA participates on the American Medical Associationís Current Procedural Terminology and Relative [Value] Update Committee panels that set codes describing medical, surgical and diagnostic services and place price values on them. These codes are the foundation for the Centers for Medicare & Medicaid Servicesí payment policies.

"Thereís no doubt that the ANAís involvement on these panels had a strong influence on the new provisions that account in real dollars for nursesí crucial contributions," Daley said. "Patients benefit from our work. Now the value of our work is being recognized through payment policy."

New payments will be awarded to nurse practitioners, clinical nurse specialists, certified nurse midwives and other primary care professionals for "transitional care management" services provided within 30 days of a Medicare patientís discharge from a hospital or similar facility.

To qualify for reimbursement, the primary care professional must contact the patient soon after discharge, conduct an in-person visit, engage in medical decision-making and provide care coordination. Care coordination involves effectively communicating and delivering a patientís needs and preferences for health services and information among a continuum of healthcare providers, functions and settings.

The Medicare Physician Fee Schedule Final Rule, set to take effect Jan. 1 after publication in the Federal Register, also includes new codes that describe "complex chronic care coordination," a service typically provided by RNs.

Although the rule does not allow separate billing for care coordination, some private insurers likely will use the codes to reimburse providers directly for the service, the ANA noted. Such reimbursement policies for care coordination could expand the RN job market and raise recognition for nurses performing this long-held, core professional standard and competency that is considered integral to patient-centered care and the effective and efficient use of healthcare resources, according to the ANA.

The rule contains several other provisions that benefit nurses by clarifying that certified registered nurse anesthetists will continue to be reimbursed for providing chronic pain management services in states where permitted by license; allowing APRNs to order portable X-rays; and ensuring nurse practitioners and clinical nurse specialists can conduct the in-person encounters required for ordering durable medical equipment for patients.


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