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ADVANCING HIGHER EDUCATION IN NURSING
One Dupont Circle NW, Suite 530 ∙ Washington, DC 20036 ∙ 202-463-6930 tel ∙ 202-785-8320 fax
www.aacn.nche.edu
September 4, 2012
Submitted via www.regulations.gov
Marilyn Tavenner
Acting Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attn: CMS–1590–P
P.O. Box 8010
7500 Security Boulevard
Baltimore, MD 21244-8010
RE: CMS–1590–P – Medicare Program; Revisions to Payment Policies Under the Physician Fee
Schedule
Dear Ms. Tavenner:
On behalf of the American Association of Colleges of Nursing (AACN), I submit the following
comments concerning the proposed rule, Medicare Program; Revisions to Payment Policies
Under the Physician Fee Schedule (77 Fed. Reg. 44721, July 30, 2012).
AACN is the national voice for America's baccalaureate and higher-degree nursing education
programs. For over four decades, the association has established quality standards for
professional nursing education to ensure that Registered Nurses (RNs) and Advanced Practice
Registered Nurses (APRNs), which include Certified Nurse-Midwives (CNMs), Certified
Registered Nurse Anesthetists (CRNAs), Nurse Practitioners (NPs), and Clinical Nurse
Specialists (CNSs), are prepared to provide evidence-based, quality, and cost-effective care.
AACN represents over 700 schools of nursing at public and private universities as well as senior
colleges across the country that educates over 360,000 students and employ more than 16,000
full-time faculty members. The students our member schools educate go on to provide care as
expert clinicians, and AACN commends CMS for recognizing the role these graduates will have
in improving the quality, efficiency, and affordability of our nation’s healthcare system through
this proposed rule.
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Section II:
H. Primary Care and Care Coordination
AACN commends CMS for its efforts in recent years to promote primary care and care coordination
in various initiatives to achieve better health outcomes and reduce healthcare expenditures. As you
are aware, primary care and care coordination are cornerstones of nursing education, particularly in
programs preparing APRNs and
Clinical Nurse Leaders
(CNLs). CNLs are RNs educated at the
master’s level to improve the quality of patient care and oversee the care coordination of a
distinct group of patients while actively providing direct patient care in complex situations. The
CNL clinician puts evidence-based practice into action to ensure that patients benefit from the
latest innovations in care delivery. This role has been embraced in healthcare settings across the
country as a leader in implementation and care coordination. As CMS continues their efforts to
design innovative models for care coordination, we urge you to include the CNL along with
other RNs and APRNs in care coordination as they are experts in this field.
AACN supports the agency’s proposal to create a HCPCS G-code that defines post-discharge
transitional care management services, including non-face-to-face services involving a beneficiary’s
transition from care provided in a hospital, skilled nursing facility, or community mental health
center to care provided by the primary healthcare professional in the community within 30 calendar
days of discharge from a designated facility. Still, we urge CMS to be inclusive of all providers,
including RNs, CNLs, and APRNs, by using provider-neutral language that recognizes the important
transitional care delivered by all qualified providers and also confirms that services delivered by
RNs, CNLs, and APRNs will be recognized and fairly compensated.
We also urge that CMS ensure RNs, CNLs, APRNs, and other qualified providers are eligible for
payment for non-face-to-face care plan oversight services. APRNs are particularly qualified, given
their education and training, to devise, implement, and oversee these plans of care. Additionally,
AACN supports the requirement that post-discharge transitional care management be provided by a
qualified healthcare provider who can assist the beneficiary in managing post-transition changes in
conditions and treatment, such as a nurse practitioner.
Overall, AACN supports CMS’s efforts to develop innovative models for payment of fee-for-service
primary care services that ensure care coordination and continuous assessment. APRNs have the
educational background and expertise to lead practice models that call for patient-centered care in a
team-based structure. In paying for these innovative models, we request that CMS exercise caution
when cutting needed healthcare services.
K. Certified Registered Nurse Anesthetists and Chronic Pain Management Services
The Institute of Medicine (IOM) reports that 100 million Americans suffer from chronic pain at an
annual cost of $600 billion per year.
1This statistic is staggering and calls for direct attention by the
full complement of healthcare providers who are trained to provide pain management services.
CRNAs are educated at the master’s or doctoral level in nationally accredited academic programs
and graduate with specialized training, skill, and expertise in providing anesthesia and pain
management. In order to address the needs of those Americans suffering from chronic pain,
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particularly in rural and underserved areas, AACN urges CMS to finalize rules restoring direct
Medicare reimbursement for chronic pain management services provided by CRNAs.
The IOM recommends that “the Medicare program include coverage of advanced practice registered
nurse services that are within the scope of practice under applicable state law, just as physician
services are now covered.”
2For over a decade, Medicare has reimbursed CRNAs directly for pain
management services as it is within their scope of practice. However, patient access to these services
was put at risk in 2011 when two Medicare administrative contractors began denying reimbursement
for CRNA chronic pain management services.
AACN urges Medicare to issue a final rule that restores direct reimbursement to CRNAs for chronic
pain management services, while not additionally burdening states to define what is “related to
anesthesia.” While states set scope of practice, they do not typically define what is “related to
anesthesia.” If states are required to define this, patient access to care could continue to be impaired.
Advanced practice nursing services, such as pain management, that are within the scope of practice
under applicable state law should be paid just as physician services are paid. To ask otherwise in the
absence of quality and outcome data creates an unnecessary regulatory barrier to these needed
services.
L. Ordering of Portable X-Ray Services
AACN supports the proposed regulation to clarify the authority of APRNs and other eligible
non-physician providers to order portable x-ray services. However, we request CMS to recognize that the
proposed regulations surrounding the ordering of portable x-ray services would not result in a change
in agency policy, but rather serve as clarification of previous conflicting guidance. Ordering of these
services falls within the scope of APRN practice and has been recognized in Medicare regulations
that authorize the ordering of diagnostic x-rays.
AACN also supports the agency’s efforts to prevent wasteful and fraudulent ordering of services that
burden the system, however, we urge CMS to recognize there are many instances in which the
delivery of portable x-ray services on the same day as services provided in a clinical setting is
appropriate patient care. We urge your careful consideration of any policies that would interfere with
or create disincentives for patients to receive necessary portable diagnostic x-ray services and to
consult with providers and suppliers on the impact of any policies on patient access to care.
Section III
C. Durable Medical Equipment (DME) Face-to-Face Encounters and Written Orders Prior to
Delivery
AACN broadly supports the agency’s effort to reduce inappropriate billing for durable medical
equipment by expanding the category of frequently ordered high-cost durable medical equipment
vulnerable to fraud and abuse that would require a detailed written order prior to delivery and require
a face-to-face encounter with the patient. However, the current statute does not allow NPs and CNSs
to independently document the face-to-face encounter despite the fact that they are authorized to
conduct examinations and order DME. Little evidence exists to suggest NPs and CNSs engage in
2 Institute of Medicine. (2011). The Future of Nursing: Leading Change, Advancing Health. Washington DC: The
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fraudulent or abusive ordering of DME, and there is little efficiency in relying on documentation by a
physician who has not evaluated the patient rather than the NP or CNS who has.
AACN is also concerned that the broad list of proposed covered items includes several that NPs and
CNSs order routinely for frequent conditions and diagnoses, such as glucose monitors. Requiring
physician documentation before these items may be supplied could lead to delays in patient care and
the potential for serious complications or conditions. We urge CMS to eliminate these statutory
obstacles to providing prompt, cost-effective care to beneficiaries.
Additionally, CNMs are not expressly identified in the face-to-face requirements detailed by the
proposed rule with respect to DME. However, CNMs and other APRNs are included in the
face-to-face requirements proposed for ordering home health services as required by Section 10605 of the
Affordable Care Act. Periodically, CNMs need to order DME products for their Medicare and
Medicaid patients and such activity is well within their scope of practice. Again, we realize the
agency is implementing a flawed statute, but we urge the Secretary to carefully consider the impact
on patients, particularly in rural and urban underserved areas, if CNMs are not able to fulfill the
face-to-face requirement for DME products.
F. Physician Compare Web Site
AACN commends CMS for focusing on the patient experience of care via the Physician Compare
website and for the PQRS Group Practice Reporting Option (GPRO). However, we find it
problematic that the agency is proposing to use as its survey tool the Clinician/Group Consumer
Assessment of Healthcare Providers and Systems (CG-CAHPS) survey; a primary-care focused tool
that chiefly seeks to capture the patient and caregiver experience with physicians. The CG-CAHPS
does not adequately capture the patient and caregiver experience with APRNs and RNs whose care is
unquestionably critical to primary care patients. We request that the agency not use the CG-CAHPS
to inform public policy decision making and urge the use of a measurement that captures the impact
patients have with the full complement of healthcare providers.
G. Physician Payment, Efficiency, and Quality Improvements—Physician Quality Reporting
System (PQRS)
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