delegation, Medicare, On the Job, Scope of Practice

Medical Assistants and the Medicare Annual Wellness Visit

There seems to be some confusion about what a medical assistant is permitted to do in connection with a Medicare Annual Wellness Visit (AWV). Let’s start with a description of a Medicare AWV from the May/June 2015 CMA Today article “Prioritizing Prevention: Medicare’s Annual Wellness Visit”:

The yearly wellness visit provides seniors with a general health-risk assessment that includes screenings for depression, cognitive impairment, and other health concerns. At the visit, health care providers review the patient’s medical and family history, docu­ment vital measurements, such as height, weight, and blood pressure, and update lists of current providers and prescriptions. At the conclusion of the visit, the patient is provided with a personal health plan, including a long-term schedule for future screenings and preventive services.

Note the following document from the Centers for Medicare & Medicaid Services (CMS), “The ABCs of the Annual Wellness Visit”:

Medicare Part B covers an AWV if performed by a:

  • Physician (a doctor of medicine or osteopathy)
  • Qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse specialist)
  • Medical professional (including a health educator, registered dietitian, nutrition professional, or other licensed practitioner) or a team of medical professionals who are directly supervised by a physician (doctor of medicine or osteopathy)

It is my legal opinion that federal law permits medical assistants to assist licensed health care providers (e.g., MDs/DOs, nurse practitioners, physician assistants) in the performing of an AWV. However, medical assistants are not permitted to perform any part of the AWV that requires the medical assistant to make independent clinical judgments or to make clinical assessments or evaluations.

Affordable Care Act (ACA), EHR Incentive Programs, Meaningful Use, Medicaid, Medicare, Scope of Practice

Congressional Action on the ACA

As our government transitions to a new administration, the following question has become increasingly common:

Would amendments to or repeal of the Affordable Care Act (ACA) affect medical assistants’ scope of practice?

The answer? Almost certainly not.  The scope of practice of medical assistants is determined primarily by state law.  An exception is the meaningful use order entry requirements of the Medicaid Electronic Health Record Incentive Program.  The Medicaid Incentive Program was not created by the ACA and would not be impacted by any amendments to or repeal of the Affordable Care Act.  Consequently, it is highly unlikely that the scope of practice for medical assistants will be impacted by congressional action on the ACA.

Certification and the CMA (AAMA) Credential, Computerized Provider Order Entry (CPOE), EHR Incentive Programs, Meaningful Use, Medicaid, Medicare, On the Job, Scope of Practice

Addressing Recent Concerns About Order Entry

The Centers for Medicare and Medicaid Services (CMS) Blog recently posted these articles dealing with forthcoming changes to the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs:

EHR Incentive Programs: Where We Go Next

Comments of CMS Acting Administrator Andy Slavitt at the J.P. Morgan Annual Health Care Conference, Jan. 11, 2016

In the wake of these pieces, there has been some concern about the potential effects on medical assistants’ ability to enter orders into the computerized provider order entry (CPOE) system for meaningful use purposes. I have addressed these concerns in a memorandum to AAMA leaders. The body of this message is as follows:

January 22, 2016

Within the last 10 days the Centers for Medicare and Medicaid Services (CMS) has issued statements about forthcoming changes in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs (Incentive Programs) required by the passage of the Medicare Access and Children’s Health Insurance Program (CHIP) Reauthorization Act of 2015, referred to as “MACRA.”

Congress enacted MACRA on April 16, 2015.  This legislation replaces the current meaningful use (MU) payment adjustment provisions with the Merit-Based Incentive Payment System (MIPS), effective January 1, 2019.  According to CMS, MIPS will incorporate some meaningful use elements of the current program and will introduce new elements.

There has been a groundswell of concern that MACRA will do away with the requirement that only third-party-credentialed medical assistants, licensed health care professionals, and third-party-credentialed individuals “who hold a more specific title than ‘medical assistant’ because their duties include only parts of the medical assisting scope of practice, or because of the specialization of the overseeing eligible professional (EP),” are permitted to enter medication, laboratory, and diagnostic imaging orders into the computerized provider order entry (CPOE) system for meaningful use calculation purposes under the Incentive Programs.

In my legal opinion, this concern is not warranted because of the following:

  1. The order entry credentialing requirement of the Incentive Programs was established by CMS rule, not by federal statute.
  2. No provisions of MACRA impact the CMS order entry credentialing requirement.
  3. The legislative history of MACRA does not indicate that Congress was concerned about the CMS order entry credentialing requirement.

CMS regulations implementing MACRA and MIPS are scheduled to be published for comment in 2016.  I do not anticipate that these forthcoming regulations will include any changes to the credentialing requirement of the CMS MU order entry rule.  However, if changes are proposed that could potentially harm patients by lowering the credentialing requirement for medical assistants who enter orders into a CPOE system, the American Association of Medical Assistants will be quick to point this out to CMS decision makers, and to persuade them to maintain or increase the current requirement.

Certification and the CMA (AAMA) Credential, Computerized Provider Order Entry (CPOE), EHR Incentive Programs, Meaningful Use, Medicaid, Medicare, On the Job, Scope of Practice

CMS Final Rule Reaffirms Credentialing Requirement for Medical Assistants

On October 6, 2015, the Centers for Medicare and Medicaid Services (CMS) issued its final rule for the Electronic Health Record (EHR) Incentive Programs. In responding to comments urging that the “credentialed medical assistant” requirement be made less stringent, CMS reaffirmed that medical assistants must have a third-party credential (such as the CMA (AAMA)), and must have sufficient knowledge to handle properly clinical decision support (CDS) alerts.

One party commenting on the CMS notice of proposed rulemaking for the EHR Incentive Programs made the suggestion “that if a standard for medical assistant CPOE [computerized provider order entry] is required, then the standard should be that the medical assistant must be appropriately trained for CEHRT [certified electronic health record technology] use (including CPOE) by the employer or CEHRT vendor in order to be counted [toward meeting the meaningful use requirements of the Incentive Programs].” (page 322 of the attached document)

CMS responded as follows:

We [CMS] disagree that the training on the use of CEHRT is adequate for the purposes of entering an order under CPOE and executing any relevant action related to a CDS. 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. (page 323 of the attached document)

This position of CMS is a resounding affirmation of the fact that only professionally-credentialed medical assistants (such as CMAs (AAMA)) are qualified to enter orders safely into the CPOE system.

More information about the CMS final rule will be forthcoming in Legal Eye: On Medical Assisting and CMA Today.

CMS Final Rule (10/6/15), pages 322-323

Computerized Provider Order Entry (CPOE), EHR Incentive Programs, Medicare, On the Job

OIG Initiates Audit Program of the Medicare EHR Incentive Program

As part of its Work Plan for Fiscal Year 2015, the Office of Inspector General (OIG) of the Department of Health and Human Services is initiating an audit program of the Medicare Electronic Health Record (EHR) Incentive Program. This audit program will be conducted in addition those already being performed by Figliozzi and Company, the audit contractor for the Centers for Medicare and Medicaid Services.

Any eligible professionals (EPs) who received incentive payments from Jan. 1, 2011, to June 30, 2014, are eligible to be randomly selected for auditing. The OIG will review certain meaningful use measures to determine whether selected EPs incorrectly received any incentive payments, and whether those EPs have adequately protected patients’ health information created or maintained by the EHR. As part of the auditing process, the agency will request specific information and documentation of compliance with the meaningful use measures under review.

To prepare for the possibility of an audit, all EPs should review their documentation for each meaningful use measure and for every year an incentive payment was received. For more information, visit the CMS meaningful use meaningful use audits webpage and access the Medical Group Management Association’s Meaningful Use Resource Center.