1	Practice Potpourri: Getting the Legal Aspects of Practice Right Lynda Woolbert, RN, PNP Executive Director Coalition for Nurses in Advanced Practice www.cnaptexas.org
2	Practice Potpourri Overview BON Authorization What is autonomous / What is delegated? Prescriptive Authority Scope of Practice Titles when Signing Documentation or Rx Ordering Services Reimbursement Red print with underlining denotes hyperlink
3	BON Authorization Serious Mistakes Continuing APN Practice but FAILING to: Maintain national certification APNs authorized on, or after 1/1/96, or whose original authorization was based on certification must maintain certification appropriate to their APN role and specialty. BON conducting audit in fall ’07. See July ’07 Texas Nursing Bulletin article. Renew APN authorization and/or Prescriptive authority with the BON Renew at same time as RN license but must check all appropriate portions and pay fees
4	BON Authorization Serious Mistakes Most Common Reasons for Failing to Properly Renew APN Authorization Did not carefully read the RN renewal application Can verify your RN license and APN authorization status on the BON Website, www.bne.state.tx.us/olv/verification.html New BON Web Address: www.tbon.state.tx.us (expect address change later fall ’07) Confused national certification with membership in a national organization
5	APN Practice Delegation to Unlicensed Assistant May a NP delegate medication administration or calling a prescription to the pharmacy to a medical or nursing assistant? NO However, if the RN assures proper training, medical or nursing assistants may administer immunizations in ambulatory settings. Also Note: Physicians may delegate the authority to call a Rx to the pharmacy for an APN if the MA has education or training equivalent to an LVN. Avoid calling Rx to pharmacy, if possible, due to high rate of medical errors. Much better to fax written Rx to the pharmacy.
6	APN Practice What is Autonomous? Assessments Histories & physical exams Ordering & interpreting diagnostic exams Recommending OTC Drugs Establishing most treatment plans in the APN’s scope of practice, excluding Rx & those requiring physician involvement (e.g. home health, hospital inpatients) Referrals & consultations Not an inclusive list
7	APN Practice What is Always Delegated? Medical Acts Establishing a Medical Diagnosis Although APNs are educated to establish a medical diagnosis, the definition of nursing in NPA prohibits any nurse from establishing that diagnosis. No physician supervision required but authority should be delegated in practice agreement/protocol. Prescriptive Authority
8	Prescriptive Authority 3 Misconceptions Common Errors & Questions
9	Prescriptive Authority Common Misconception #1 A physician can only delegate to 3 APNs in all sites. FACT Only applies to Primary Practice Site / Alternate Practice Site and Long-term Care Facility-based Practice.
10	Prescriptive Authority Common Misconception #2 A physician must do a 10% chart review in all sites. FACT Only applies to Medically Underserved and Alternate Practice Sites
11	Prescriptive Authority Common Misconception #3 Physicians must co-sign when reviewing charts. FACT Co-signature is never required or recommended. If a physician reviews charts, keep a log.
12	Prescriptive Authority Common Serious Errors No Protocol or not reviewed annually and signed Not adhering to site-based requirements Assuming the physician knows requirements for delegating prescriptive authority
13	Prescriptive Authority Most Serious Errors Assuming the BON Rx Authority # is all that is required to sign a prescription APN must be practicing in a qualifying site; and Physician must delegate through signing the practice protocol Prescribing for Patients Outside of Scope Prescribing Controlled Substance without a valid DPS permit & DEA license No protocol or including items in protocol not consistent with current law
14	Prescriptive Authority What is the Practice Protocol? “Protocol” is a legally defined term in Texas law and Medical Board Rule §193.2. Not like protocols in a hospital or treatment guidelines. More like a “practice agreement” because it only contains certain delegation statements and legal requirements for the physician and NP See CNAP Sample Protocol
15	Prescriptive Authority Warning! Pain or weight loss clinics may not be legitimate For guidance on standards for pain management, see TMB Rule 170.1 – 170.3
16	Prescriptive Authority Common Question Must the physician have the same specialty as the NP? No, but physician’s specialty should be closely related to NP’s Practice for purposes of consultation and referral e.g. A FNP who sees no children or pregnant women – physician could be an Internist WARNING: NP must verify physician has a valid, unrestricted Texas Medical license. http://reg.tmb.state.tx.us/OnLineVerif/Phys_NoticeVerif.asp?
17	Prescriptive Authority Common Question May more than one physician delegate to an APN at the same time? Yes No limit on the number of physicians who may delegate Rx Authority to an APN Must maintain a protocol with each.
18	Prescriptive Authority Common Question Do I have to notify any agency if the physician who delegates Rx Authority changes? Yes, if the APN has a DPS #, must notify the Department of Public Safety http://www.txdps.state.tx.us/ftp/forms/ModPAAPN.pdf Do not notify Medical or Nursing Boards
19	Prescriptive Authority Common Question Does the physician have to notify the Texas Medical Board (TMB) about delegation of Rx Authority? NO Since 2005, the physician must maintain records, but does not notify the TMB
20	Prescriptive Authority References Nursing Board Rules §222 Medical Practice Act §157.051 -.060, Occupations Code Medical Board Rules §193.2 (certain definitions) and §193.6
21	Scope of Practice
22	Scope of Practice (SOP) Violating SOP boundaries is the most common cause for disciplinary action and bad outcomes. Must be able to validate your scope is within the boundaries of your formal APN education.
23	Scope of Practice Most Common Question Is a primary care educated NP permitted to practice in a hospital? YES If the patient is stable; and Conditions being treated are an extension of formal APN education
24	Scope of Practice Common Question Is a primary care educated NP permitted to practice in a specialty? YES
25	Scope of Practice Common Question Is a primary care educated NP permitted to participate in the medical management of patients in an ICU? NO Primary care education does not include management of unstable patients in the ICU or unstable patients in any other unit. However, there may be situations in which a primary care educated NP may consult on treating specific conditions in an ICU.
26	Scope of Practice Common Question Is a primary care educated NP practicing in a specialty permitted to consult on a patient in ICU? YES, if managing a stable condition Examples: ANP specializing in orthopedics consulting on fractured tibia of an adult patient in the ICU PMHNP consulting on mental health issues
27	Scope of Practice Common Question Is an ACNP primary care educated NP permitted to provide primary care? NO
28	Scope of Practice Common Question Is a FNP permitted to: diagnose and treat depression? YES, minor depression within limits of education provide psychological counseling? NO, could only provide anticipatory guidance and refer
29	Scope of Practice Question I am recognized by the BON as a PNP-PC but I am also nationally certified as a CPNP-AC. May I refer to myself as a CPNP-AC? NO May I participate in medical management of Pediatric ICU patients based on my national certification? NO May I drop my PNP-PC certification? NO
30	Scope of Practice Reference “Guidelines for Determining Scope of Practice with FAQs on Scope of Practice” www.bne.state.tx.us/practice/gen-apn.html
31	How to Sign Your Name
32	Ordering Services Common Question May I order diagnostic exams? YES APN Guide includes a letter from the BNE confirming this is in an APN’s SOP Other restrictions may apply If ordering services at a hospital, must have privileges Medicaid rules have not been updated and physician must order for the lab or facility to be reimbursed.
33	Ordering Services Common Question May I order home health? NO Also restricts ability to order other services in home health
34	Ordering Services Common Question May I order orthodics? NO Not permitted in Orthotist/Prosthetist Practice Act May order OT, PT, Speech Therapy (except Medicaid)
35	Ordering Services Common Question May I order durable medical equipment (DME)? YES, for Medicare CMS published guidelines in 2002 permitting NPs & CNSs to order DME Medicaid rules have not been updated to permit NPs or CNSs to order DME.
36	Ordering Services Common Question Must the orders I write in inpatient settings be co-signed? NO However, requirements in medical staff bylaws prevail.
37	Reimbursement Common Questions & Issues
38	Reimbursement Common Question What are reimbursement rates if the NP bills under own provider number? Medicare – 85% Texas Medicaid – 92% (except certain services such as THS, labs & immunizations are 100%) Private Insurance – Variable from 65% to 100%. NPs should negotiate for 85% or higher (§1451.106, Insurance Code)
39	Reimbursement Common Question
40	Medicare Physician Billing for NP Services “Incident to” applies to Outpatient Settings Only Requires the physician to: Perform initial evaluation; Have ongoing involvement in care; and Be in the office suite when the service is delivered. www.trailblazerhealth.com/Publications/Training%20Manual/incident_to.pdf
41	Medicaid Physician billing for NP Services Physicians may bill for NP services if: Physician & NP established a collaborative agreement / protocols Physician uses the “SA” modifier Applies to both inpatient & outpatient settings No direct supervision required HHSC Rule - 1 TAC §354.1062
42	Private Insurance Physician Billing for NP Services Based on individual company policies and contractual requirements If no policies, base on Medicare. Option: Notify company by certified mail, return receipt, that practice is using Texas Medicaid standards for physician billing. No response is agreement.
43	Inpatient Settings Medicare Billing for NP Services Shared visits – Physician may bill the combined services of the physician and NP (may allow higher E&M code) Not permitted if visit is a consult Physician must be paying for the NP’s services or both employed by same group Potential Fraudulent Billing Physician billing for services provided by NP employed by the hospital.
44	Inpatient Settings Common Question May a hospital bill for services provided by NPs it employs? Yes, if: NP’s salary & benefits are removed from hospital’s cost report Services being billed would not be included in the global fee Potential Fraudulent Billing Double billing would occur if the hospital & physician are billing for the same services.
45	Reimbursement Common Question Does co-signing the note permit the physician to bill for the service? NO Co-signing does not permit the physician to bill in either inpatient or outpatient settings.
46	National Provider Identifier (NPI) Common Question Does the NP need a NPI if the NP is not billing? YES The NPI will be the universal identifier. Used for ordering procedures and as a prescriber identifier for prescriptions
47	National Provider Identifier (NPI) Single identifier # for all health plans began 5-23-07, including Medicare & Medicaid Phase in through 5-23-08 Letter explaining NPI: access at www.cms.hhs.gov/hipaa/hipaa2/npi-provider.pdf Medicaid is transitioning now so include both NPI and Medicaid Provider #
48	Avoid Reimbursement Disasters Plan how the practice will bill services before the APN starts work. (45 -60 days) Be sure managed care (MC) contracts are consistent with billing plan. If you bill MC plans under the APN’s name, be sure the APN is a listed provider.
49	Questions? Contact Lynda Woolbert Executive Director Coalition for Nurses in Advanced Practice lynda@cnaptexas.org (979) 345-5974 (512) 750-3747 www.cnaptexas.org
50	Questions? Contact Lynda Woolbert Executive Director Coalition for Nurses in Advanced Practice lynda@cnaptexas.org (979) 345-5974 (512) 750-3747 www.cnaptexas.org