"Ask NE GAPNA Members" Question

Susan, thanks for asking. What NPs are permitted to do (and not do) under Medicare and State regs is a constant discussion at the facility I work at in CT. The following issues come up often:
- Can NPs admit patients to SNF?
- Can NPs write code status orders in a SNF in CT?
- Can NPs perform and bill for 30 day reviews?
- Can NPs perform and bill for annual exams?
- Can NPs order portable xrays?
- Can NPs sign face to face sheets?
- Does a facility need to have protocols for APRN practice?
- Can NPs bill wound debridement codes for sharp instrument wound debridement in a SNF?

Hi Susan, I am in MA and some NH's will not allow NP's to give a verbal order for RN pronouncement when a patient dies. I find this interesting since we can pronounce, but not give an order to pronounce? Do you have any information on this?

Rebecca, I have been told that in NH's in CT as well in the past, but have not seen that since laws changed and allowed NPs to pronounce.

Hi Rebecca and Elizabeth, thanks for your responses. I will definitely include these questions in the guidelines. For now, though, NPs cannot do the admission at a skilled facility (which means don't call it an admission and don't bill for it, but we often do most or all of the work since we often see the patient first). We CAN admit and bill patients to long term care. We can write code status, perform and bill for annuals, order xrays and debride IF you have been trained in debridgement and it is in your collaborative agreement. We can perform F2F but not sign it. Most facilities have an agreement with all providers in order to have privileges there, not protocols. And Rebecca, if the physician is unavailable, we can pronounce or give the order to pronounce (I wish the availability clause wasn't in there). Thanks for your great questions!

Rebecca,
Did you know that NPs can now sign death certificates?

Hi Susan, NPs in CT cannot write code status orders (unlike in mass), and it is my understanding that no one can use the wound debridement codes (CPTs) 11042 - 11044 in a SNF to bill Medicare, but that we can write a general note and bill 99307-99310 to bill for time/complexity after doing wound debridement. Also, you noted above that NPs CAN admit to ltc...isn't that SNF? I thought we were not allowed to admit to SNF?? Please keep us updated with your handbook. Would love to purchase a copy once you have completed!

Hi Elizabeth,
According to CMS, we can admit to nursing homes, which means long term care but NOT to skilled nursing homes, meaning subacute care. I am not an expert in CPT codes, but I will look into it. I DO know that if a NP is trained in wound debridement, he/she can do it.

While viewing the painful process of identifying nursing home practice boundaries, I am happy and optimistic toreport good news from CT: we may actually get to independent practice in this legislative session! article by Drs. Cusson and Alexander: https://www.facebook.com/pages/Connecticut-Advanced-Practice-Registered-Nurse-Society/106655529403686

and track the CT General Assembly bill: http://www.cga.ct.gov/asp/cgabillstatus/cgabillstatus.asp?selBillType=Bill&bill_num=SB00036

For our colleagues in MA, certainly it is one of the first steps in defining your LTC or rehab facility manual is to have your state's practice act, the supervisory contract between the APRN-MD and the APRN position description of the Long Term Care/Rehab/Residential facility. I would think all of the MD and facility contracts would be different..?? a good opportunity for a focus group.
Also perhaps to stir the pot again for independent practice like NY, FL, VA system and CT! :)

Although it is very exciting that CT may become an independent state for NPs, it will have less of an impact on NPs in Geriatrics that bill Medicare routinely. Unfortunately, Medicare requires NPs to have a collaborative agreement with a physician, EVEN if the state no longer requires this.