Update to Medicare policy manual requires scope of practice documentation

Effective today, when a nurse practitioner or a clinical nurse specialist certifies eligibility and orders services for a Medicare patient, additional documentation will be required in the medical record.

A new update to Chapter 7 of the Medicare Benefit Policy Manual requires nurse practitioners to document their scope of practice and the relationships they have with physicians with whom they are collaborating. The update was published on April 27 2022 (MLN Matters Number: MM12615 revised). The implementation date for this requirement is May 26, 2022.

“This change is a language clarification to make it clear that nurse practitioners or clinical nurse specialists acting as allowed practitioners under the Medicare benefit must work in collaboration with a physician, and meet state scope of practice laws,” said Kim Skehan, SimiTree Director of Compliance and Regulatory.

Allowing practitioners other than the physician to certify Medicare patients and order services was approved two years ago under the Coronavirus Aid, Relieve and Economic Security Act (CARES Act), which amended the Social Security Act in response to COVID-19.

The CARES act permits nurse practitioners, clinical nurse specialists and physician assistants who are working in collaboration with a physician to certify and order services for Medicare patients, as long as state laws do not prohibit it.

State law prevails

Authorization from the Centers for Medicare and Medicaid Services (CMS) is secondary to state laws establishing scope of practice, Skehan noted. Nurse practitioners, clinical nurse specialists and physician assistants are required to practice in accordance with state law in the state in which services are performed.

“This has been a continuing area of confusion during the pandemic,” Skehan said. “States vary widely in what they do and no not allow, regarding whether a practitioner may work independently without a written collaborative agreement or supervision from a physician, or whether general or direct supervision and collaboration is required.”

The update to the Medicare Benefit Policy Manual addresses the problem by requiring documentation in the medical record of scope of practice and the practitioner’s relationships to the physician.

“In the absence of state law governing collaboration, collaboration is to be evidenced by documentation of the scope of practice in the medical record,” Skehan said. “And the medical record should also indicate the relationships between the practitioner and the physician to deal with issues outside their scope of practice.”

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