5101:3-8-22 Advanced practice nurses practice arrangements and reimbursement.

(A) Advanced practice nurses enrolled in the Ohio medicaid program may practice in a variety of practice or employment arrangements as specified in the nurse's standard care arrangement in accordance with section 4723.431 of the Revised Code. Whether an advanced practice nurse or a group of advanced practice nurses is entitled to direct reimbursement under the Ohio medicaid program is dependent entirely on the practice or employment arrangement of the advanced practice nurse or group.

(B) Practice arrangements.

(1) Independent practice.

An "advanced practice nurse" is considered to be in an independent practice if the medical services rendered to a patient are the responsibility of an advanced practice nurse who is in solo practice or a member of an advanced practice nurse group practice and the practice is free of the fiscal, administrative, and professional control of an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, a long term care facility, or any other medicaid provider. "Free of professional control" does not mean that the advanced practice nurse practices in the absence of a standard care arrangement. Each advanced practice nurse, including those in independent practice as defined in this rule, must maintain a standard care arrangement as required by section 4723.431 of the Revised Code.

(2) Provider-based practice.

An "advanced practice nurse" is considered to be in a provider-based practice if the advanced practice nurse is under the fiscal, administrative and professional control of an individual physician practice, a physician group practice, a hospital, a fee-for-service clinic, a cost-based clinic, a long term care facility, or any other medicaid provider through an employment, a contractual, or any other legally binding arrangement. Advanced practice nursing services provided in provider-based practices are considered incidental to the employing or contractual provider (i.e., as physician services if provided in a physician-based practice, as clinic services if provided in a clinic-based practice, as hospital services if provided in a hospital-based practice, etc.).

(C) Reimbursement.

(1) Services provided by advanced practice nurses are subject to the site differential payments set forth in rule 5101:3-4-02.2 of the Administrative code and the office incentive payments set forth in rule 5101:3-4-09 of the Administrative Code.

(a) The total reimbursement for services and procedures subject to the site differential payment is either the provider's billed charge or the reimbursement rate established in paragraphs (C)(3) and (C)(4) of this rule multiplied by the site differential percentage rate, whichever is less.

(b) The total reimbursement for services and procedures subject to the office incentive payment is either the provider's billed charges or the reimbursement rate established in paragraphs (C)(3) and (C)(4) of this rule plus the incentive payment rate, whichever is less.

(2) Separate reimbursement is not available for any service included in the global payment of another service (e.g., evaluation and management services provided for post-operative care), whether the global payment was made directly to the advanced practice nurse or to another medicaid provider.

(3) Only advanced practice nurses who practice in an independent practice arrangement are eligible to bill and receive direct reimbursement under the Ohio medicaid program. For independent practices, reimbursement is the lesser of the provider's billed charge or one of the following:

(a) Eighty-five per cent of the medicaid maximum when services are provided in a hospital setting; or

(b) One hundred per cent of the medicaid maximum when services are provided in a nonhospital setting.

(4) Services provided by advanced practice nurses in provider-based practices are reimbursable only to the employing or contracting provider.

(a) For individual physician-based practices, group physician-based practices, fee-for-service clinic-based practices, or hospital-based practices;, reimbursement for advanced practice nursing services is the lesser of the provider's billed charge or one of the following:

(i) Eighty-five per cent of the medicaid maximum when services are provided by an advanced practice nurse in the following places of service: inpatient hospital, outpatient hospital, or hospital emergency department; or

(ii) One hundred per cent of the medicaid maximum when services are provided by an advanced practice nurse in any nonhospital place or service.

(b) For RHC-based, FQHC-based and OHF-based practices, reimbursement for advanced practice nursing services is the medicaid maximum set forth in Chapters 5101:3-16, 5101:3-28, and 5101:3-29 of the Administrative Code, respectively.

(c) For all other nonhospital, provider-based practices, reimbursement for advanced practice nursing services is bundled into the payment for that provider type and is the maximum allowed under the medicaid program for the services rendered by that provider type (e.g., services provided by a nurse practitioner employed by a home health agency would be bundled into the payment for a home health service).

(d) When services incident to advanced practice nurse services are provided by an individual who is not an advanced practice nurse in an office or clinic setting, the services rendered must be within the scope of licensure (if licensure is required) of the individual who is not an advanced practice nurse or a service for which the individual is legally authorized to provide under Ohio law and documented in the patient's medical records.

(i) The services rendered by the individual who is not an advanced practice nurse must be rendered under the direct supervision of the advanced practice nurse. The records must be reviewed and countersigned by the supervising advanced practice nurse.

(ii) "Direct supervision" in the advanced practice nurse's office or clinic setting means-that the advanced practice nurse must be present in the office suite throughout the time the individual who is not an advanced practice nurse is providing the service and immediately available to provide assistance and direction throughout the time the individual who is not an advanced practice nurse is performing services. Direct supervision does not mean the advanced practice nurse must be in the same room while the individual who is not an advanced practice nurse is providing services. The availability of the advanced practice nurse by telephone or the presence of the advanced practice nurse somewhere in the institution does not constitute availability.

(iii) All of the provisions relating to direct supervision described in rule 5101:3-4-02 of the Administrative Code must be met.

(5) Hospital-based advanced practice nurses.

(a) For hospital-based practices, separate reimbursement is available to hospitals for professional services provided by advanced practice nurses only if the requirements set forth in paragraph (C)(5)(c) of this rule are met. Reimbursement for professional services provided by hospital-based advanced practice nurses is in accordance with paragraph (C)(4)(a) of this rule. In addition, certain services are subject to the site differential payment in accordance with paragraph (C)(1) of this rule.

(b) Services provided by advanced practice nurses that include teaching, research, administration, supervision of professional and/or technical personnel, supervision of nursing and advanced practice nursing students, service on hospital committees, and other hospital-based activities that are of benefit to patients, generally do not meet all of the requirements set forth in paragraph (C)(5)(c) of this rule.

(i) Such services are reimbursable only as hospital services and are bundled into the hospital's inpatient or outpatient facility payment in accordance with Chapter 5101:3-2 of the Administrative Code; and

(ii) The portion of the expenses associated with the provision of the type of services identified in paragraph (C)(5)(b) of this rule by an advanced practice nurse, may be included on the hospital cost report.

(c) Reimbursement for services rendered directly to, and for the benefit of, individual patients by advanced practice nurses who are employed by or under contract with a hospital is separately reimbursable to the hospital on a fee-for-service basis as advanced practice nursing services (i.e., in addition to the inpatient or outpatient hospital facility payment) if the following requirements are met:

(i) The services are personally furnished for an individual patient by an advanced practice nurse who is currently enrolled as an Ohio medicaid provider.

(ii) The services contribute directly to the diagnosis or treatment of an individual patient.

(iii) The services ordinarily require performance by a physician or an advanced practice nurse.

(iv) The services are not the type of services routinely performed by registered nurses or other hospital-employed nonphysicians.

(v) For services identified in paragraphs (C)(5)(c)(i) to (C)(5)(c)(iv) of this rule, documentation must exist that demonstrates the advanced practice nurse's involvement in the service rendered. A countersignature alone in the records is not considered sufficient documentation of advanced practice nursing services.

(vi) The portion of the expenses associated with the provision of the type of services identified in paragraphs (C)(5)(c)(i) to (C)(5)(c)(iv) of this rule by advanced practice nurses are excluded from the hospital cost report.

(6) In an institutional setting, advanced practice nurses will only be reimbursed by the medicaid program for the services that have been personally rendered by the advanced practice nurse.

Effective: 01/01/2008
R.C. 119.032 review dates: 05/15/2007 and 01/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 4723.41 to 4723.50
Prior Effective Dates: 9/24/83, 4/1/88, 5/15/89, 3/1/94 (Emer), 5/12/94, 5/1/97, 6/1/02