Physician Delegation: Standing Orders

Under the laws of most states, physicians are permitted to delegate by means of standing orders to knowledgeable and competent medical assistants as long as the following conditions are met:

  1. The standing order is understood by the medical assistant
  2. The standing order is for a task that is delegable to medical assistants under the laws of the state, and the delegating physician is exercising the degree of supervision required by the laws of the state
  3. The standing order is applicable to all patients without exception
  4. The standing order does not require the medical assistant to exercise independent professional judgment, or to make clinical assessments, evaluations, or interpretations
Posted in delegation, On the Job, Scope of Practice, Uncategorized | Tagged , | 4 Comments

Order Entry Requirements for Non-Physician Practitioners

I was recently asked whether non-physician practitioners (e.g., nurse practitioners and physician assistants) must meet the meaningful use order entry requirements under the Medicaid Electronic Health Record (EHR) Incentive Program.  The answer is yes.

The following are considered “eligible professionals” (EPs) who can participate in the  Medicaid EHR Incentive Program:

  • Physicians (primarily doctors of medicine and doctors of osteopathy)
  • Nurse practitioners
  • Certified nurse-midwives
  • Dentists
  • Physician assistants who furnish services in a Federally Qualified Health Center or Rural Health Clinic that is led by a physician assistant

All participating EPs must meet the computerized provider order entry (CPOE) requirements of the Incentive Program in order to receive incentive payments.

Posted in Computerized Provider Order Entry (CPOE), EHR Incentive Programs, Eligible Professionals, Medicaid, On the Job | Tagged , , , , , | Leave a comment

Medical Assisting across State Lines

I recently received the following two questions:

  1. Is a medical assistant permitted to cross state lines and work in two different states at the same time?
  2. Are there any CMAs (AAMA) working as “traveling medical assistants,” similar to “traveling RNs”?

 

A medical assistant is permitted to work in two different states as long as the medical assistant is abiding by the medical assisting laws in both states, and meets any credentialing requirements in the two states.

There is nothing in the laws of any state that forbids a medical assistant from working for more than one employer.  If that is your definition of a “traveling medical assistant,” it is permissible for a CMA (AAMA) to work in in this capacity.

 

Posted in On the Job, Professional Identity, Scope of Practice | 18 Comments

AAMA Submits Comments to HHS

The AAMA recently submitted comments concerning the proposed rule for the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive to the U.S. Department of Health and Human Services. What follows is the full text of those comments.

Department of Health and Human Services
Centers for Medicare & Medicaid Services (CMS)
42 CFR Parts 414 and 495

File Code: CMS—5517—P

Federal Register, Vol. 81, No. 89, pages 28161—28686
Monday, May 9, 2016

Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models; Proposed Rule

The following comments are being submitted on behalf of the American Association of Medical Assistants (AAMA), the national organization representing the medical assisting profession at the federal and state levels, in regard to the above-captioned proposed rule.

I. Computerized Provider Order Entry (CPOE) and Protection of Patients; Excerpts from the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs Stage 3 Final Rule (October 16, 2015)

The American Association of Medical Assistants is in total agreement with the following excerpts from the “Medicare and Medicaid Programs; Electronic Health Record Incentive Programs—Stage 3 and Modifications to Meaningful Use in 2015 Through 2017; Final Rule” (80 FR 62762 through 62955), October 16, 2015:

(Page 62798, second column)

In the Stage 2 final rule (77 FR 53986) and in subsequent guidance in FAQ 9058, we explained for Stage 2 that a licensed health care provider or a medical staff person who is a credentialed medical assistant or is credentialed to and performs the duties equivalent to a credentialed medical assistant may enter orders. We maintain our position that medical staff must have at least a certain level of medical training in order to execute the related CDS [clinical decision support] for a CPOE order entry…

(Page 62839, second column)

…We believe CPOE and CDS duties should be considered clinical in nature, not clerical.  Therefore, CPOE and CDS duties, as noted, should be viewed in the same category as any other clinical task, which may only be performed by a qualified medical or clinical staff person.

In keeping with the above excerpts, it is the position of the AAMA that only appropriately credentialed medical assistants (in addition to licensed health care professionals) should be permitted to enter medication, laboratory, and diagnostic imaging orders into the computerized provider order entry system for meaningful use calculation purposes under the Medicaid Electronic Health Record Incentive Program, and for advancing-care-information purposes under the Merit-Based Incentive Payment System (MIPS).  Without this requirement, the welfare of patients would be jeopardized.

II. The Primary and Alternate Proposals for Calculating the Advancing-Care-Information Performance Category Base Score in the Proposed Rule

The AAMA takes notice of the following excerpts from the Executive Summary of the proposed rule:

(Page 28220, third column)

The primary proposal…of this proposed rule would require a MIPS eligible clinician to report the numerator (of at least one) and denominator…for a subset of measures adopted by the EHR Incentive Programs for EPs [eligible professionals] in the 2015 EHR Incentive Programs Final Rule.  In an effort to streamline and simplify the reporting requirements under the MIPS, and reduce reporting burden on MIPS eligible clinicians, two objectives (Clinical Decision Support and Computerized Provider Order Entry) and their associated measures would not be required for reporting the advancing-care-information performance category.  Given the consistently high performance on these two objectives in the EHR Incentive Programs with EPs accomplishing a median score of over 90 percent for the last 3 years, we believe these objectives and measures are no longer an effective measure of EHR performance and use…

(Page 28221, first column)

The alternate proposal…of this proposed rule would require a MIPS eligible clinician to report the numerator (of at least one) and denominator…for all objectives and measures adopted for Stage 3 in the 2015 EHR Incentive Programs Final Rule to earn the base score portion of the advancing-care-information performance category, which would include reporting a…numerator and denominator for Computerized Provider Order Entry objectives.  We include these objectives in the alternate proposal as MIPS eligible clinicians may feel the continued measurement of these objectives is valuable to the continued use of EHR technology as this would maintain the previously established objectives under the EHR Incentive Programs.

We believe both proposed approaches to the base score are consistent with the statutory requirements and previously established certified EHR technology requirements as we transition to MIPS…

(Page 28227, first and second columns)

Objective: Computerized Provider Order Entry (Alternate Proposal Only)

Objective: Use computerized provider order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant, who can enter orders into the medical record per state, local, and professional guidelines.

III.  The Medicaid EHR Incentive Program continues to require the reporting of all objectives and measures for Stage 3 of the October 16, 2015, Final Rule, as does the alternate proposal in the proposed rule. 

The AAMA takes notice of the following excerpts from the Executive Summary of the proposed rule:

(Page 28233, third column, and page 28234, first column)

We note that the Medicaid EHR Incentive Program for EPs was not impacted by the MACRA [Medicare Access and CHIP Reauthorization Act of 2015] and the requirement under section 1848(q) of the Act to establish the MIPS program.  In this rule, we do not propose any changes to the objectives and measures previously established in rulemaking for the Medicaid EHR Incentive Program, and thus EPs participating in that program must continue to report on the objectives and measures under the guidelines and regulations of that program.

Accordingly, reporting on the measures specified for the advancing-care-information performance category under MIPS cannot be used as a demonstration of meaningful use for the Medicaid EHR Incentive Program.  Similarly, a demonstration of meaningful use in the Medicaid EHR Incentive Program cannot be used for purposes of reporting under MIPS.

Therefore, MIPS eligible clinicians who are also participating in the Medicaid EHR Incentive Program must report their data for the advancing-care-information performance category through the submission methods established for MIPS in order to earn a score for the advancing-care-information performance category under MIPS, and must separately demonstrate meaningful use in their state’s Medicaid EHR Incentive Program in order to earn a Medicaid incentive payment. The Medicaid EHR Incentive Program continues through payment year 2021, with 2016 being the final year an EP can begin receiving incentive payments (§495.310(a)(1)(iii)). We solicit comments on alternative reporting or proxies for EPs who provide services to both Medicaid and Medicare patients and are eligible for both MIPS and the Medicaid EHR Incentive Program.

IV. To reduce duplicative reporting and to simplify the process, the AAMA recommends that all MIPS eligible clinicians (ECs) who continue to participate as eligible professionals (EPs) in the Medicaid EHR Incentive Program be required to report in accordance with the alternate proposal in the proposed rule. 

The AAMA appreciates the opportunity to offer recommendations in regard to the reporting options “for EPs who provide services to both Medicaid and Medicare patients and are eligible for both MIPS and the Medicaid EHR Incentive Program.”

To restate the above-excerpted paragraph beginning on line 102, by enacting the MACRA, Congress did not alter the Medicaid EHR Incentive Program.  Consequently, the measures and objectives for the Medicaid EHR Incentive Program delineated in the aforementioned Final Rule (October 16, 2015) are not affected by the provisions of the proposed rule.  Thus, for example, the following language in the Code of Federal Regulations will continue to be in effect for Medicaid Eligible Professionals (EPs) through payment year 2021:

Section 495.24  Stage 3 meaningful use objectives and measures for EPs, eligible hospitals, and CAHs for 2018 and subsequent years

(d) Stage 3 objectives and measures for EPs, eligible hospitals, and CAHs

(4) Computerized provide order entry (CPOE)—(i) EP CPOE—(A) Objective.  Use computerized provide order entry (CPOE) for medication, laboratory, and diagnostic imaging orders directly entered by any licensed healthcare professional, credentialed medical assistant, or a medical staff member credentialed to and performing the equivalent duties of a credentialed medical assistant, who can enter orders into the medical record per state, local, and professional guidelines.

(1) More than 60 percent of medication orders created by the EP during the EHR reporting period are recorded using computerized provider order entry;

(2) More than 60 percent of laboratory orders created by the EP during the EHR reporting period are recorded using computerized provider order entry; and

(3) More than 60 percent of diagnostic imaging orders created by the EP during the EHR reporting period are recorded using computerized provider order entry.

Under the proposed rule, Eligible Clinicians (ECs) in the MIPS would be allowed to report in accordance with either the primary proposal or the alternate proposal. If these professionals continue to participate in the Medicaid Incentive Program as Eligible Professionals (EPs), they would have to “separately demonstrate meaningful use in their state’s Medicaid EHR Incentive Program in order to earn a Medicaid incentive payment.” In order to avoid the situation of an EC in the MIPS reporting under the primary proposal, and the same individual as an EP in the Medicaid Incentive Program reporting with a much greater degree of detail in order to comply with meaningful use and receive an incentive payment, the American Association of Medical Assistants recommends to the Centers for Medicare and Medicaid Services that the language of the proposed rule be changed to require MIPS ECs who are also EPs in the Medicaid Incentive Program to utilize the alternate proposal for reporting under the Merit-Based Incentive Payment System.  This revision to the rule would minimize duplicative reporting and confusion for ECs/EPs, and would facilitate auditing by CMS of compliance with both programs.

Thank you for your consideration.  Questions about these comments can be directed to Donald A. Balasa, JD, MBA, AAMA CEO and Legal Counsel, at dbalasa@aama-ntl.org

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Medical Assisting Students and CPOE

I have been asked whether medical assisting students doing their practicums/externships are permitted to enter orders into the computerized provider order entry (CPOE) system and have such entry count toward the meaningful use thresholds under the Medicare and Medicaid Incentive Programs.  The following is my response:

During their practicum/externship, students are not permitted to enter medication, laboratory, or diagnostic imaging orders into the CPOE system and have such entry count toward meeting the meaningful use requirements of the Medicare and Medicaid Incentive Programs.  However, it is my legal opinion that externing students—as specifically directed by the overseeing/delegating provider at the practicum site—are permitted to draft orders that a supervising credentialed medical assistant or licensed health care professional reviews.  The credentialed medical assistant or the licensed professional can then enter the orders into the CPOE system and discuss with the externing student any clinical decision support alerts that are generated.  If this approach is followed, the externing student will be able to learn about electronic order entry, and—because the order was entered by a credentialed medical assistant or licensed health care professional—the entry can be included in the meaningful use calculations for the Incentive Programs.

Posted in Uncategorized | 2 Comments