The CMS rule creates reimbursement opportunities for RNs

The American Nurses Association touted a brand new Medicare rule that calls for advanced practice RNs to be paid for primary care services geared toward effectively managing patients? transferring from hospital to a different location while stopping complications and conditions that result in costly readmissions.

This rule also creates latest 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 satisfy this demand. (For more information, please 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 within the transitional care section.)

With as much as 20% of Medicare patients readmitted to hospitals inside 30 days of discharge, greater importance has been placed on effective transition care and care coordination. “The American Nurses Association has been advocating for years that government and private insurers recognize nurses’ contributions to transitional care and care coordination and pay appropriately for these essential services,” ANA President Karen A. Daley, RN, PhD, MPH, FAAN, wrote in a press release. “This Medicare rule is a huge step forward for nurses, whose knowledge and skills play a major role in patient satisfaction and quality of care.”

The 2012 ANA report, “The Value of Nurse-Managed Care Coordination” (www.nursingworld.org/carecooperativewhitepaper), highlighted quite a few studies demonstrating the positive impact of nurse-managed care coordination. Studies have shown that care coordination reduces ED visits, hospital readmissions, and drug costs; lowers overall annual Medicare costs; improves patient satisfaction and confidence in self-managing care; and increases the protection of older adults when moving between facilities.

The ANA participates within the American Medical Association’s Current Procedural and Relative Terminology [Value] Update Committee panels that establish codes that describe medical, surgical and diagnostic services and place pricing values ​​on them. These codes are the premise of the Centers for Medicare and Medicaid Services? payment rules.

“There is no doubt that ANA’s involvement on these panels has had a strong impact on new regulations that settle critical nurse contributions in real dollars,” Daley said. “Patients benefit from our work. Now the value of our work is recognized through our payment policy.”

The latest payments will go to nurse practitioners, clinical nurse practitioners, certified midwives and other primary care providers for “transitional care management” services provided inside 30 days of a Medicare patient’s discharge from a hospital or similar facility.

To be eligible for reimbursement, a primary care physician must contact the patient shortly after discharge from the hospital, conduct an in-person visit, engage in medical decision-making, and supply care coordination. Care coordination involves the effective communication and delivery of a patient’s needs and preferences for health services and data amongst various health care entities, facilities, and facilities.

The Medicare Physician Fee Schedule final rule, which takes effect on January 1 after publication within the Federal Register, also includes latest codes to explain “complex chronic care coordination,” a service typically provided by RNs.

While the rule doesn’t allow separate billing for care coordination, some private insurers will likely use the codes to directly reimburse providers for services, ANA noted. Such care coordination reimbursement policies could expand the RN job market and increase recognition for nurses practicing these long-standing skilled standards and competencies which can be considered integral to patient-centered care and the effective and efficient use of health care resources, in response to the ANA.

The rule includes several other provisions that profit nurses by clarifying that registered nurse anesthetists will proceed to be reimbursed for providing chronic pain management services in states where licensure allows it; allowing APRNs to order portable x-rays; and providing nurses and clinical nurses with the power to conduct face-to-face meetings required to order durable medical equipment for patients.