5101:3-8-23 Advanced practice nurses: coverage and limitations.

(A) The coverage of services provided by advanced practice nurses shall be limited only to the extent that the condition of the patient and/or the limited scope of practice of an advanced practice nurse as it is recognized under Ohio law warrants the intervention and/or care of a physician in a capacity other than one of advisory, collaborating, or for the purposes of prescribing pharmaceuticals or medical devices when the advanced practice nurse lacks prescriptive authority.

(B) Chapter 5101:3-14 of the Administrative Code and all the rules set forth in Chapter 5101:3-4 of the Administrative Code that pertain to services a physician is legally authorized to perform under Ohio law shall apply to advanced practice nurses except, the term "physician" as it is defined in rule 5101:3-4-01 of the Administrative Code shall be replaced with the term"advanced practice nurse" as it is defined in rule 5101:3-8-21 of the Administrative Code.

(C) In addition to being subject to the applicable rules set forth in Chapter 5101:3-4 of the Administrative Code, advanced practice nurses are subject to the following coverage and limitations:

(1) For services provided in a teaching setting for advanced practice nurses, paragraphs (A) and (E)(2) in rule 5101:3-4-05 of the Administrative Code shall apply except the term"physician" in this rule shall be replaced by the term "advanced practice nurse" and the term "resident, intern, or fellow" shall be replaced by the term "individual in training for an advanced practice nursing certification.".

(2) Under no circumstances will an advanced practice nurse be eligible to bill or be reimbursed for the following evaluation and management CPT code: 99223,

(3) Consultations performed by an advanced practice nurse are covered.

(4) Except when precluded by Ohio law, inpatient hospital evaluation and management services are covered only if the advanced practice nurse is acting in the capacity of the patient's "primary treating provider" for the day and no physician is acting concurrently as the primary treating provider, and billing for evaluation and management services. For purposes of this rule, "primary treating provider" is a physician or advanced practice nurse who is responsible for managing the patient's inpatient hospital care for that day. "Primary treating provider" does not include a sub-specialist provider who may be treating the patient concurrently for specialty care, (e.g. a nephrologist).

(5) Antepartum services may be provided by advanced practice nurses who are certified in an advanced practice nurse specialty that is qualified to perform antepartum services.

(6) "Covered nurse midwifery services" are defined as those services that constitute the management of preventive services and those primary care services necessary to provide health care to women antepartally, intrapartally, postpartally, and gynecologically. Only advanced practice nurses who are certified nurse midwives may perform and bill for deliveries. In addition, the following services are noncovered when performed by nurse midwives, except in unavoidable, emergency situations:

(a) Management of an acute obstetric emergency, including any obstetric operation;

(b) Version or delivery of breech or face presentation; and

(c) Use of forceps;

(7) Therapeutic injections, prescribed drugs, diagnostic and therapeutic services, laboratory services, and radiology services are covered as an advanced practice nursing service only if the service was ordered and/or prescribed by a physician, an advanced practice nurse, or any other provider who has the authority to order and/or prescribe the services under, and in accordance with, Ohio law.

(8) With the exception of those laboratory procedures listed as physician-performed microscopy procedures (PPMP), laboratory services that require performance by a pathologist or a physician who is regarded as a specialist in pathological or hematological medicine (e.g., physician professional services associated with the gross or microscopic examination of surgical pathology tissues), are not covered if they are performed by an advanced practice nurse.

(9) Professional radiology or diagnostic and therapeutic services are covered by an advanced practice nurse if the advanced practice nurse is within his or her scope of practice.

(10) If a physician and an advanced practice nurse provide the same covered service, (e.g. any evaluation and management service), or participate in the provision of a global/all-inclusive service that involves multiple visits on the same or different days, only one provider is entitled to reimbursement for the service.

(a) Unless otherwise agreed upon by the two providers, the physician or the employing provider of the physician shall be the provider entitled to reimbursement if the condition of the patient and/or the limited scope of practice of an advanced practice nurse warrants the intervention and/or care of a physician in a capacity other than one of advisory, collaborating, or for the purpose of prescribing pharmaceuticals, medical devices, or other diagnostic and therapeutic services when the advanced practice nurse lacks the prescriptive authority required.

(b) Separate reimbursement is not available for the physician's supervision of or collaboration with an advanced practice nurse. Any cost associated with the supervisory role of a physician is the responsibility of the advanced practice nurse or advanced practice nurse group if the advanced practice nurse is in an independent practice arrangement, or the responsibility of the employing provider if the advanced practice nurse is in a provider-based practice arrangement.

(D) The following services are noncovered:

(1) Emergency room visit codes 99284 and 99285 are not covered if billed by an advanced practice nurse who is in an independent practice as defined in rule 5101:3-8-22 of the Administrative Code.

(2) All services exceeding the policies and limitations defined in Chapters 5101:3-1, 5101:3-4 and 5101:3-14 of the Administrative Code and rules 5101:3-8-20 and 5101:3-8-25 of the Administrative Code;

(3) All services exceeding the scope of practice of an advanced practice nurse under, and in accordance with, Ohio law;

(4) Any service exceeding the scope of practice of an advanced practice nurse as defined in the standard care arrangement;

(5) Services determined by the department as not medically necessary as defined in rule 5101:3-1-01 of the Administrative Code or that are duplicative in respect to a service provided concurrently by a physician or other valid medicaid provider;

(6) Assistant-at-surgery services;

(7) Services of residents, interns, and fellows provided in a teaching setting supervised by an advanced practice nurse; and

(8) All services itemized as noncovered in rule 5101:3-4-28 of the Administrative Code.

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, 3/1/94 (Emer), 5/12/94, 5/1/97, 6/1/02