Help our students! (and Preceptors)

Many of you may have received this notice from NAPNAP, but it's worth broadcasting again to all of you.  Hosting NP (or PA) students is an important aspect of our jobs--how else do they learn if we don't play a role in that learning process?  However; the fact that Preceptors must "re-do" the note *simply* for billing purposes is a bit ludicrous.  Recently, a ruling was made for PHYSICIAN providers that they only have to 'verify' the student's note in the chart (and certainly make corrections/additions as needed) as opposed to rewrite the note.   A blessing for all, improved efficiency, as well as helpful to the learner.  BUT...non-Physician providers were left out of this ruling.  Below is information in regards to this issue and how you can help.  Please send in comments to the Government to once again open their eyes that there are more than Physicians out there providing care to our populations.  We are all providers of health care; let's be treated as such!  

Recent federal policies on the documentation of evaluation and management services provided by nurse practitioner students and verified by nurse practitioner preceptors are threatening to reduce opportunities for nurse practitioner students to receive clinical instruction. 

NAPNAP members have an opportunity to help correct this policy by submitting comments on the proposed rule for the 2019 Medicare Part B fee schedule (CMS-1693-P).  Comments must be submitted to the agency by midnight Monday, September 10. 

Background

Prior to March 5, 2018 for billable evaluation and management (E/M) services, all clinical preceptors (teachers) had to re-document the clinical notes of medical students, nurse practitioner (NP) students and physician assistant (PA) students.  The Centers for Medicare & Medicaid Services (CMS) released Transmittal 3971 (subsequently Transmittal 4068), revising the Medicare Claims Processing Manual, effective March 5, 2018, to allow teaching physicians to verify in the medical record any student documentation of the components of E/M services, rather than re-document the work.  Unfortunately, the agency didn't extend the same burden reduction to NP and PA students and their NP and PA preceptors, even though they fill the same role as teaching physicians.

The new policy has the unintended consequence of increasing the disparity between services provided by medical students and NP and PA students, as well as the documentation standards for teaching physicians and precepting NPs and precepting PAs.  These disparities have already led some facilities to be less willing to train NP and PA students and raised an additional barrier to recruitment of NP and PA preceptors. 

Regulatory Comments

On July 27, 2018, CMS released proposed regulations for the 2019 Medicare Part B fee schedule, commonly referred to as the "physician fee schedule." That rule proposes unrelated changes to teaching physician policies – but it offers the opportunities for PNPs to urge the agency to address the policies that disadvantage NP students and preceptors.  Since the problematic policies proposed in March have already gone into effect and started to impact NP students and preceptors, CMS should act immediately to adjust its policies to provide equitable treatment of teaching physicians and NP and PA preceptors.

We are calling on NAPNAP members to submit comments (instructions below) recommending the following changes to current policies:

1.   Apply the Teaching Physician Documentation Requirements to All E/M Visits

In the proposed fee schedule rule, CMS is already suggesting policies to reduce documentation redundancy for all E/M visits.  By applying the March 2018 teaching physician requirements from Transmittal 4068 to all E/M visits, the agency can reduce duplicative policies for all E/M visits, including E/M visits documented by NP and PA students and verified by NP and PA preceptors.  CMS can accomplish this through its current rulemaking and have it go into effect immediately.

1.   Provide equitable policies for Teaching Physicians and NP and PA Preceptors, and for Medical Students and NP and PA Students

CMS can also acknowledge the role of NP and PA preceptors and students by extending regulations and guidance for teaching physicians and medical students to include NP and PA preceptors and students.  To accomplish this, the agency should:

•  Include NP preceptors and PA preceptors in the definition of "teaching physician." The Secretary has statutory authority to define "teaching physician" and could include NP and PA preceptors, preferably using the term "teaching clinician."  If CMS believes such a change would require additional rulemaking, the Secretary could use his existing waiver authority or issue a nonenforcement instruction to Medicare carriers to immediately extend the teaching physician policies to NP and PA preceptors.
•  Include NP and PA Students in the interpretation of "Student." CMS has the authority to interpret the word "student" in Transmittal 4068 to include NP and PA students. The term "student" is not defined in regulation, and the existing definition of "student" in the Medicare Claims Processing Manual already includes NP and PA students.  Harmonizing this interpretation could be accomplished through guidance, would not require rulemaking.

How to Submit Comments on Documentation and Precepting Of NP Student Services

1. Go to the website Regulations.gov (https://www.regulations.gov/comment?D=CMS-2018-0076-0621).
2. Type your comments in the text box provided – or upload comments written in a separate document or file.
1.  Use the background information and policy recommendations provided above in drafting your comments.
2.  It is critically important for you to provide examples of how these policies could have a damaging impact on your students and your institution. Anecdotal evidence of the harm these policies will do is very valuable.

1. Complete the form with your name and contact information.
2. When complete, click on the "Continue" arrow. On the next page, review your comment and information – then click the box that you understand you are submitting publicly viewable comments and click "Submit Comments."
3. You will have an opportunity to have a receipt for your comments e-mailed to you, if you choose, to an address that you provide.

 Thank you for engaging in this important advocacy effort!