500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 1 (401)

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1 Medical Cverage Plicy Mid-Level Practitiner sad EFFECTIVE DATE: 02/02/2006 POLICY LAST UPDATED: 10/01/2013 OVERVIEW This plicy dcuments services cvered when rendered by a BCBSRI credentialed Mid-level practitiners (MLP) functining in a cllabrative relatinship with a physician r as an independent practitiner. PRIOR AUTHORIZATION Nt applicable POLICY STATEMENT Cverage and Cntracting: Certified Nurse Specialists: This describes a registered nurse with Master's r PhD preparatin in ne f the fllwing areas: medical-surgical nursing; adult psychiatric-mental health nursing; child r adlescent psychiatric health and mental health nursing. BCBSRI des nt cntract with r credential medical-surgical clinical nurse specialists. Therefre, this sectin f the plicy addresses psychiatric and mental health clinical nurse specialists. Under Rhde Island state law, clinical nurse specialists may have prescriptive privileges and are required t have a cllabrative agreement with a participating physician when using prescriptive privileges. BCBSRI cntracts with Psychiatric and Mental Health Clinical Nurse Specialists (CNS) wh meet credentials requirements t prvide cvered mental health services. CNS prviders with prescriptive privileges must have a cllabrative agreement cnfrming t BCBSRI credentials plicy and prcedures. The State f Rhde Island mandates cverage in accrdance with RIGL : Cntracts with subscribers. Each nnprfit medical service crpratin may cntract with its subscribers fr any medical service as may be prvided under any nnprfit medical service plan adpted by the crpratin; prvided, that: 2) If any medical service as may be prvided fr shall include service which may be lawfully perfrmed r rendered by a certified registered nurse practitiner r psychiatric and mental health nurse clinical specialist, the cntract will prvide fr the payment fr the service perfrmed r rendered by a certified registered nurse practitiner r psychiatric and mental health nurse clinical specialist t subscribers. N nnprfit medical service crpratin may require supervisin, signature, r referral by any ther health care prvider as a cnditin f reimbursement t a certified registered nurse practitiner; prvided that n nnprfit medical service crpratin may be required t pay fr duplicative services actually rendered by bth a certified registered nurse practitiner and any ther health care prvider. Prvider restrictins apply please see Behaviral Health Plicy. Registered Nurse Practitiners (RNP): The RNP describes a registered nurse with a minimum f a Master's preparatin frm an educatinal prgram which includes bth didactic and clinical cmpnents. They are certified by exam after cmpleting required clinical practice hurs. They practice in an expanded rle utilizing independent knwledge f physical assessment and management f health care and illness. This practice includes prescriptive privileges and cllabratin with ther health care prfessinals. The fllwing credentialing agencies validate, based n predetermined standards, an individual registered nurses knwledge, skills and abilities in a defined, functinal area f nursing: 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 1

2 American Academy f Nurse Practitiners (AANP) American Assciatin f Critical Care Nurses (AACN) Certificatin Prgram American Nurses Credentialing Center Natinal Certificatin Crpratin fr Obstetric, Gyneclgic and Nenatal Nursing Specialties Natinal Bard n Certificatin f Hspice and Palliative Care Nurses (NBCHPN) Onclgy Nurses Certificatin Crpratin Pediatric Nursing Certificatin Bard (PNCB) The State f Rhde Island mandates cverage in accrdance with RIGL : Health insurance cntracts - Certified registered nurse practitiners and psychiatric and mental health nurse clinical specialists. a) Every health insurance cntract, plan, r plicy delivered, issued fr delivery, r renewed in this state shall prvide cverage fr the services f a certified registered nurse practitiner, practicing cllabratively, r in the emply f a physician licensed under chapter 37 f title 5, and psychiatric and mental health nurse clinical specialists, t subscribers if the services are within the certified registered nurse practitiner's r psychiatric and mental health nurse clinical specialist's area f prfessinal cmpetence as established by educatin and certificatin, and are currently reimbursed when rendered by any ther licensed health care prvider. N insurer r hspital, medical service crpratin, r health maintenance rganizatin may require the signature, by any ther health care prvider as a cnditin f reimbursement. N insurer r hspital, medical service crpratin, r health maintenance rganizatin may be required t pay fr duplicative services actually rendered by bth a certified registered nurse practitiner and any ther health care prvider. (c) Every health insurance cntract, plan, r plicy delivered, issued fr delivery, r renewed in this state shall prvide cverage fr certified registered nurse practitiners t prvide primary care, intermediate, hme, lng-term and inpatient care as primary care prviders, when said certified registered nurse practitiner is a participating prvider, cnsistent with, and practicing within, the scpe f his/her prfessinal license. (d) Ntwithstanding any law t the cntrary, all insurers, nnprfit medical service crpratins, nnprfit hspital service crpratins and health maintenance rganizatins shall prvide subscribers with an pprtunity t select a certified registered nurse practitiner, wh is a participating prvider, as a primary care prvider. (e) Ntwithstanding any law t the cntrary, all insurers, nnprfit medical service crpratins, nnprfit hspital service crpratins and health maintenance rganizatins shall insure that all participating primary care prvider certified registered nurse practitiners are included n any publicly accessible list f participating prviders fr the respective rganizatin. BCBSRI cntracts with RNPs wh meet credentialing requirements t prvide cvered health services. All RNPs have prescriptive privileges and must have a cllabrative agreement cnfrming t BCBSRI credentialing plicy and prcedures. RNPs scpe f practice includes but is nt limited t; prviding r arranging services fr patients may rder referrals t specialists, diagnstic tests (labratry, machine tests and imaging studies), hme care, durable medical equipment (DME), supplies and as allwed by their prescriptive privileges, medicatins including injected r infused drugs and bilgics. Members may designate RNPs credentialed as primary care prfessinals t be their primary care prfessinal. RNPs affiliated with a specialist cannt be chsen as an RNP-PCP. As a temprary measure due t claims system limitatins, members are instructed t select the cllabrating PCP as prxy fr the RNP. Physician Assistants (PA): A physician's assistant is a graduate f an apprved PA prgram, usually Master's prepared level after cmpletin f a Bachelr's prepared degree and experience in a health care setting. They wrk under the supervisin f a physician with a written agreement that delineates their scpe f practice. These respnsibilities ften include, but are nt limited t; physical examinatins, diagnsing and treating 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 2

3 illnesses, rdering and interpreting tests, and limited prescribing privileges. Certificatin is by the Natinal Cmmissin f Certificatin f Physician Assistants. BCBSRI cntracts with PAs wh meet credentialing requirements t prvide cvered health services. All PAs must have a supervisry/cllabrative agreement cnfrming t BCBSRI credentialing plicy and prcedures. PAs prviding r arranging services fr patients may rder referrals t specialists, diagnstic tests (labratry, machine tests and imaging studies), hme care, durable medical equipment (DME), supplies and as allwed by their prescriptive privileges, medicatins including injected r infused drugs and bilgics. Certified Registered Nurse First Assistants (CRNFA): The CRNFA is a registered nurse with a minimum f five years f clinical/didactic educatin, certificatin, and experience. These five years wuld include at least tw in the perating rm milieu and achievement f CNOR status (Certificatin in Operating Rm Nursing), and ne academic year f tertiary educatin. Respnsibilities may include preperative, intraperative, and pst-perative duties. Mst typically, the CRNFA's rle is as first assistant, intraperatively handling tissue, prviding expsure, using instruments, suturing, and prviding hemstasis. The State f RI mandates cverage in accrdance with RIGL Third party reimbursement fr services f registered nurse first assistants. a) Every individual r grup health insurance cntract, plan r plicy delivered, issued r renewed by an insurer r nnprfit r fr prfit health service crpratin which prvides benefits t individual subscribers and members within the state, r t all grup members having a principal place f emplyment within the state, shall prvide benefits fr services rendered by a registered nurse first assistant, prvided, that the fllwing cnditins are met: (1) The registered nurse first assistant prvides certain health care services under the supervisin f a licensed physician; is currently licensed as a registered nurse in Rhde Island; has successfully cmpleted a curse in preparing the registered nurse as a first assistant in accrdance with the Assciatin f Operating Rm Nurses cre curriculum guide fr the registered nurse first assistant and includes a minimum f ne academic year in a cllege r university with didactic instructin and clinical internship prgrams; and is certified in periperative nursing by the Certificatin Bard f Periperative Nursing (minimum f tw years periperative experience); (2) The plicy r cntract currently prvides benefits fr identical services rendered by a prvider f health care licensed by the state; and (3) The registered nurse first assistant is nt a salaried emplyee f the licensed hspital r facility fr which the nnprfit hspital service crpratin has an alternative cntractual relatinship t fund the services f a registered nurse first assistant. (b) It remains within the sle discretin f the nnprfit medical service crpratin as t which registered nurse first assistant in surgery it cntracts with. Reimbursement is prvided accrding t the respective principles and plicies f the nnprfit medical service crpratin: prvided that n nnprfit medical service crpratin is required t prvide direct reimbursement, r pay fr duplicative services actually rendered by a registered nurse first assistant and any ther health care prvider. Nthing cntained in this sectin precludes the nnprfit medical service crpratins frm cnducting managed care, medical necessity r utilizatin review. BCBSRI cntracts with CRFNAs wh are nt emplyees f facilities and wh meet credentialing requirements fr the prvisin f cvered assistant-at-surgery services. Certified Nurse Midwives: Midwives must have cmpleted an educatinal prgram in midwifery that is accredited by the American Cllege f Nurse-Midwives and pssess dcumentatin f supervised clinical practice f at least ne year's duratin. The license t practice midwifery authrizes the hlder t attend cases f nrmal childbirth, t prvide prenatal, intrapartum and pstpartum care, including the immediate care f the newbrn and 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 3

4 well wman gyneclgical care with evidence f prearranged prvisin fr cllabratin with a physician in accrdance with the American Cllege f Nurse-Midwives and the American Cllege f Obstetrics and Gyneclgy. The State f RI mandates cverage in accrdance with RIGL : Cntracts with subscribers. Each nnprfit medical service crpratin may cntract with its subscribers fr any medical service as may be prvided under any nnprfit medical service plan adpted by the crpratin; prvided, that: 3) If any medical service as may be prvided fr shall include service which may be lawfully perfrmed r rendered by a licensed midwife, the cntract delivered, issued fr delivery, r renewed in this state shall prvide fr the payment fr the service perfrmed r rendered by a licensed midwife in accrdance with each health insurers' respective principles and mechanisms f reimbursement credentialing and cntracting if thse services are within the licensed midwives' area f prfessinal cmpetence as defined by regulatins prmulgated pursuant t , and are currently reimbursed when rendered by any ther licensed health care prvider. N nnprfit medical service crpratin may require supervisin, signature, r referral by any ther health care prvider as a cnditin f reimbursement except when the requirements are als applicable t ther categries f health care prviders; prvided, n insurer r hspital r medical service crpratin r patient may be required t pay fr duplicate services actually rendered by bth a licensed midwife and any ther health care prvider. Direct payment fr licensed midwives will be cntingent upn services rendered in a licensed health care facility and fr services rendered in accrdance with rules and regulatins prmulgated by the department f health; prvided, that this prvisin shall nt prhibit payment fr services pursuant t r fr ther services reimbursed by third party payrs. BCBSRI cntracts with CNMs wh meet credentialing requirements t prvide cvered health services. CNMs prviding r arranging services fr patients may rder referrals t specialists, diagnstic tests (labratry, machine tests and imaging studies), hme care, durable medical equipment (DME), supplies and as allwed by their prescriptive privileges, medicatins including injected r infused drugs and bilgics. Certified Registered Nurse Anesthetists (CRNA): This practitiner is a registered nurse wh has graduated frm an educatin prgram accredited by the American Assciatin f Nurse Anesthetists Cuncil n Accreditatin f Nurse Anesthesia Educatin Prgrams. They prvide certain services under the supervisin f anesthesilgists, licensed physicians, r licensed dentists, in accrdance with the state law which requires substantial specialized knwledge, judgment and skill related t the administratin f anesthesia including: preperative and pst-perative patient assessments,, mnitring patients during anesthesia, management f fluid intravenus therapy and respiratry care. State f RI mandates cverage in accrdance with RIGL : Third party reimbursement fr services f certain health care wrkers. (a) Every individual r grup health insurance cntract, plan r plicy delivered, issued r renewed by an insurer r nnprfit r fr prfit health service crpratin which prvides benefits t individual subscribers and members within the state, r t all grup members having a principal place f emplyment within the state, shall prvide benefits fr services rendered by a certified registered nurse anesthetist designated as a certified registered nurse anesthetist by the bard f nurse registratin and nursing educatin; prvided, that the fllwing cnditins are met: (1) The certified registered nurse anesthetist prvides certain health care services under the supervisin f anesthesilgists, licensed physicians r licensed dentists in accrdance with (c), which requires substantial specialized knwledge, judgment and skill related t the administratin f anesthesia, including preperative and pst- 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 4

5 perative assessment f patients; administering anesthetics; mnitring patients during anesthesia; management f fluids in intravenus therapy and management f respiratry care; (2) The plicy r cntract currently prvides benefits fr identical services rendered by a prvider f health care licensed by the state; and (3) The certified registered nurse anesthetist is nt a salaried emplyee f the licensed hspital r facility fr which the nnprfit medical service crpratin has an alternative cntractual relatinship t fund the services f a certified registered nurse anesthetist. (b) It shall remain within the sle discretin f the nnprfit medical service crpratin as t which certified registered nurse anesthetists it shall cntract with. Reimbursement shall be prvided accrding t the respective principles and plicies f the nnprfit medical service crpratin; prvided, that n nnprfit medical service crpratin may be required t pay fr duplicative services actually rendered by a certified registered nurse anesthetist and any ther health care prvider. Nthing cntained in this sectin shall preclude the nnprfit medical service crpratin frm cnducting managed care, medical necessity r utilizatin review. BCBSRI cntracts with CRNA s meeting credentialing requirements wh are nt hspital emplyees fr the prvisin f cvered anesthesia services. Payment: "Incident-t" services: BCBSRI des nt fllw Medicare and des nt pay physicians fr services f mid-level prviders incident-t. Mid-level prviders must be individually credentialed by BCBSRI and filed under their wn prvider number. Shared Visits: BCBSRI allws shared visit billing, s lng as the service is allwed by regulatin, facility plicy and scpe f practice. BCBSRI defines a shared visit is when a physician and an MLP bth see the patient n the same date and the physician bills fr the cmbined service. In such cases bth are invlved in the assessment and medical decisin-making prcesses in a meaningful way. Bth have direct (i.e. facet-face) patient cntact. The selectin f the Evaluatin and Management (E/M) cde level is based upn the cmbined dcumentatin f the tw prfessinals. Time-based reprting will nly be allwed based upn physician time. The Centers fr Medicare and Medicaid Services (CMS) limits shared visits t specific CPT cdes (fr example, the cncept des nt apply fr nursing facility services). BCBSRI des nt apply the CMS restrictins. In n case are bth prfessinals practicing in the same discipline (as defined by the specialty f the cllabrating physician) allwed t each reprt services n the same date. Fr example, if an RNP sees a patient and feels the cllabrating physician shuld als see the patient that day and arranges fr this t ccur, the shared visit principle applies and nly ne service is reprted. Hwever, if a primary care practice RNP refers a patient t a specialist n the same date, the RNP and specialist are nt sharing the visit. Exceptin: A physician may reprt pharmaclgic treatment/evaluatin, n the same date a CNS withut prescribing privileges reprts psychtherapy services. Acute Hspital Inpatient Services: During an acute hspital inpatient stay a MLP may prvide services. E/M services in the inpatient setting may be shared visits but are nt therwise eligible fr payment t the MLP. In rder fr any inpatient services t be medically necessary (including the inpatient stay r thse f the MLP ) the attending physician must daily dcument the need fr cntinued stay. Cncurrent care services are nly medically necessary when prvided by a specialist physician with distinct expertise frm that f the attending physician. Time based services (e.g., critical care, prlnged services) must be perfrmed by physicians. Acute inpatient care requires daily physician attendance. If the nly clinician representing the attending physician is a MLP, the hspital is ineligible t receive acute inpatient reimbursement fr the day in questin as n physician has dcumented the cntinued need fr inpatient level f care. Discharge day services are exempt frm this requirement. Admissin services may be claimed n the day rendered by a MLP withut physician face-t-face cntact n 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 5

6 that day, s lng as the physician cntact ccurs within the next 24 hurs (e.g., a single day after admissin physician cntact with tw distinct days f shared services being reprted, an admissin and a single subsequent care service, is acceptable). Surgical glbal perids apply and MLPs may nt bill fr services within the glbal perid when prviding pst-perative care. Exceptin: NPs and PAs that are wrking with a hspital facility based inpatient practice may be given exceptin t the restrictin n reprting any E/M services. In such cases, the physician must be readily available n-site thrughut rutine business hurs. It is expected that there is rutine cmmunicatin with the physician(s) in caring fr the patient, even if the physician des nt persnally see the patient. It is preferred that the physician peridically see the patient n wrk runds with the inpatient team during the stay. The MLP must be wrking within the scpe f privileges granted by the hspital. Behaviral health MLPs (Psychiatric and Mental Health Clinical Nurse Specialists) may prvide E/M r psychiatric diagnstic interview services t patients n medical/surgical units. Fr behaviral units r behaviral health facilities there is n exceptin. Skilled Nursing Facility (SNF)/Nursing Facility (NF) Services: Only physicians may cmplete the admissin assessment by regulatin. Hwever, BCBSRI allws the physician t utilize infrmatin cllected by the MLP in a shared visit methdlgy fr the admissin assessment. A single claim is submitted by the physician. The MLP may prvide medically necessary services prir t the admissin assessment. BCBSRI will nt allw a shared visit fr the admissin assessment when this ccurs if the MLP reprts thse urgent initial services. The physician may nly reprt the admissin services persnally perfrmed when the MLP reprts a service perfrmed prir t the admissin assessment. Only physician s nurse practitiners, clinical nurse specialist r physician assistants that are nt facility emplyees may certify skilled level f care. The physician may delegate interval visits t the MLP s lng as the physician sees the patient again by day 60 and again by day 120. Inpatient Rehabilitatin Services : MLPs that have been granted clinical privileges by the facility may perfrm admissin assessment s lng as they are cnfirmed by the physician within 72 hurs. Only ne admissin assessment is allwed per stay, e.g., the MLP and physician may nt bth bill fr the admissin assessment. On n date shall the physician and the MLP bth bill fr subsequent care services when the tw are acting as attending physicians and supprt fr the attending service r when in the same cverage grup. There shall be an attending physician assigned t every patient and the MLP shall be clearly assciated with the attending physician. MLPs may nt prvide cnsultant services in this setting except as a shared visit. Hme and Dmiciliary Care: MLPs may perfrm hme care and dmiciliary care fr cvered health services when prviding care in a manner cnsistent with their cllabrative/supervisry agreement. The MLP shall bill using their individual prvider number. Assistant-at-Surgery: Payment fr assistant-at-surgery shall fllw the same rules fr eligible prcedures as fr physicians. Assistant-at-surgery services are eligible fr payment when rendered by a CRNFA, PA, NP r CNS. Assistant at surgery claims fr PAs, NPs and CNSs must be submitted with the AS mdifier. Anesthesia services: BCBSRI requires the use f anesthesia mdifiers t reprt the services f the CRNA and physician, when applicable. 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 6

7 Mderate (Cnscius) Sedatin Cnscius sedatin cdes are allwed by CRNA, NP r PA. Certifying Services and Ordering Diagnstic Studies: Fr purpses f determining eligibility fr payment f services RNP, PA and CNM may rder diagnstic studies (e.g., lab, imaging, machine tests) using their individual prvider identifier. RNP, PA, CNM and CNS with prescriptive privileges may rder medicatins as allwed by licensure laws. RNP, PA, and CNM may certify hme care and DME. Only physicians and RNPs which are nt facility emplyed may certify SNF care. Referrals frm PCP t Specialists: CNM, PA and RNP prfessinals that are cntracted with BCBSRI as part f a PCP cllabrative practice may make specialist referrals fr thse prducts that require PCP referral fr the member t receive maximum benefits. MEDICAL CRITERIA Nne BACKGROUND Mid-level practitiner is a term used t describe prfessinal, licensed persnnel wh functin either in a cllabrative relatinship with a physician r as an independent practitiner t prvide cvered health care services t patients. An advanced level f academic preparatin; specific training and certificatin by exam is required. There are legal and regulatry definitins f the types f services that each f the practitiners may perfrm within the scpe f their license and practice. Als, BCBSRI has practice standards fr cntracting and credentialing mid-level practitiners (BCBSRI Plicy CR 2.3 Credentialing) fr the fllwing prfessinals: Certified Nurse Specialists (CNS) with r withut prescriptive privileges Registered Nurse Practitiners (RNP) Physician Assistants (PA) Certified Registered Nurse First Assistants (CRNFA) Certified Nurse Midwives (CNM) Certified Registered Nurse Anesthetists (CRNA) COVERAGE Benefits vary between grup/cntract. Please refer t the apprpriate Evidence f Cverage r Subscriber Agreement fr applicable benefits/cverage. *Cvered Health Services as defined in the Subscriber Agreement. CODING Cding and Reimbursement fr Mid-Level Practitiners: All services perfrmed by a mid-level practitiner shuld be billed using apprpriate cdes as defined by CPT-4, ICD-9, ICD-10, and HCPCS II. Mid-level practitiners must bill using their individual prvider identificatin number prvided by the Plan, except as nted fr "shared visit" billing. Mid-level practitiner when acting as an assistant-at-surgery must bill using an AS mdifier. Services perfrmed by mid-level practitiners are paid at a cntracted prprtin f the physician fee schedule. 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 7

8 The fllwing services billed by a mid-level practitiner will be reimbursed at 100 percent f the physician fee schedule allwance when cvered: Labratry services Injected r infused drugs Supplies After-hurs services RELATED POLICIES Behaviral Health Skilled Nursing Facility PUBLISHED Prvider Update Dec 2013 Prvider Update Aug 2011 Prvider Update Aug 2008 Prvider Update May 2006 REFERENCES N Nne e i CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS This medical plicy is made available t yu fr infrmatinal purpses nly. It is nt a guarantee f payment r a substitute fr yur medical judgment in the treatment f yur patients. Benefits and eligibility are determined by the member's subscriber agreement r member certificate and/r the emplyer agreement, and thse dcuments will supersede the prvisins f this medical plicy. Fr infrmatin n member-specific benefits, call the prvider call center. If yu prvide services t a member which are determined t nt be medically necessary (r in sme cases medically necessary services which are nn-cvered benefits), yu may nt charge the member fr the services unless yu have infrmed the member and they have agreed in writing in advance t cntinue with the treatment at their wn expense. Please refer t yur participatin agreement(s) fr the applicable prvisins. This plicy is current at the time f publicatin; hwever, medical practices, technlgy, and knwledge are cnstantly changing. BCBSRI reserves the right t review and revise this plicy fr any reasn and at any time, with r withut ntice. Blue Crss & Blue Shield f Rhde Island is an independent licensee f the Blue Crss and Blue Shield Assciatin. 500 EXCHANGE STREET, PROVIDENCE, RI MEDICAL COVERAGE POLICY 8