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One Dupont Circle NW, Suite 530 ∙ Washington, DC 20036 ∙ 202-463-6930 tel ∙ 202-785-8320 fax

September 4, 2012

Submitted via

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


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.



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.


This 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,



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.”


For 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


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


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



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)



eligible for the EHR Incentive Program. Providers such as CRNAs who are currently ineligible for

federal incentive payments to adopt interoperable health information technology must not be

penalized in Medicare payment for not having the EHR systems that federal programs currently deny

them. To the extent that the value-based payment modifier could apply to all eligible professionals,

including CRNAs, we ask that CMS clarify that CRNAs and other providers who were not eligible

for the EHR incentive payment/modification under the enabling statute not be subject to the

downward payment adjustment in the value-based payment modifier for not being reported as a

meaningful user of EHR.

Thank you for the opportunity to respond to this call for comments. Please contact Dr. Suzanne

Miyamoto, AACN’s Director of Government Affairs, for any additional information at 202-463-6930

ext. 247 or






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