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.

Centers for Medicare & Medicaid Services, Computerized Provider Order Entry (CPOE), EHR Incentive Programs, Medicaid, Uncategorized

Eligible Professionals in the Medicaid EHR Incentive Program

I would like to note the recent update on eligible professionals (EPs) from the Centers for Medicare & Medicaid Services:

EPs that attest directly to a state for that state’s Medicaid EHR Incentive Program will continue to attest to the measures and objectives finalized in the 2015 EHR Incentive Programs Final Rule (80 FR 62762 through 62955). In 2017, Medicaid EPs have the option to report to the Modified Stage 2 or Stage 3 objectives and measures.

As a reminder, the following are considered to be EPs under the Medicaid Incentive Program:

  • Doctors of medicine
  • Doctors of osteopathy
  • Doctors of dental medicine or surgery
  • Nurse practitioners
  • Certified nurse midwives
  • Physician assistants (PAs) when working at a federally qualified health center or rural health clinic that is so led by a PA

Finally, please note the following language from the 2015 final rule, which is referred to in the previous block quote and is attached at the end of this post:

We are adopting the objective for EPs, eligible hospitals and CAHs [critical access hospitals] as follows:

Objective 4: Computerized Provider Order Entry

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.

Measure 1: More than 60 percent of medication orders created by the EP or authorized providers of the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry;

  • Denominator: Number of medication orders created by the EP or authorized providers in the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
  • Numerator: The number of orders in the denominator recorded using CPOE.
  • Threshold: The resulting percentage must be more than 60 percent in order for an EP, eligible hospital, or CAH to meet this measure.
  • Exclusion: Any EP who writes fewer than 100 medication orders during the EHR reporting period.

Measure 2: More than 60 percent of laboratory orders created by the EP or authorized providers of the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry; and

  • Denominator: Number of laboratory orders created by the EP or authorized providers in the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
  • Numerator: The number of orders in the denominator recorded using CPOE.
  • Threshold: The resulting percentage must be more than 60 percent in order for an EP, eligible hospital, or CAH to meet this measure.
  • Exclusion: Any EP who writes fewer than 100 laboratory orders during the EHR reporting period.

Measure 3: More than 60 percent of diagnostic imaging orders created by the EP or authorized providers of the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period are recorded using computerized provider order entry.

  • Denominator: Number of diagnostic imaging orders created by the EP or authorized providers in the eligible hospital or CAH inpatient or emergency department (POS 21 or 23) during the EHR reporting period.
  • Numerator: The number of orders in the denominator recorded using CPOE.
  • Threshold: The resulting percentage must be more than 60 percent in order for an EP, eligible hospital, or CAH to meet this measure.
  • Exclusion: Any EP who writes fewer than 100 diagnostic imaging orders during the EHR reporting period.

Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 3 and Modifications to Meaningful Use in 2015 Through 2017; Final Rule

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.

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.

CMS Stage 2 Rule, Computerized Provider Order Entry (CPOE), EHR Incentive Programs

CMS NPRM Expands Category of Radiology Orders, Thresholds

As a follow-up to my post yesterday, the March 20, 2015, Centers for Medicare and Medicaid (CMS) notice of proposed rulemaking (NPRM) for Stage 3 of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs has expanded the category of radiology orders to include diagnostic imaging other than radiology.  Also, the thresholds for medication, laboratory, and diagnostic imaging orders have been increased for Stage 3.  Note the following excerpts from the CMS NPRM:

We propose to continue our policy from the Stage 2 final rule that the orders to be included in this objective are medication, laboratory, and radiology orders, as such orders are commonly included in CPOE implementation and offer opportunity to maximize efficiencies for providers. However, for Stage 3, we are proposing to expand the objective to include diagnostic imaging, which is a broader category including other imaging tests such as ultrasound, magnetic resonance, and computed tomography in addition to traditional radiology. This change addresses the needs of specialists and allows for a wider variety of clinical orders relevant to particular specialists to be included for purposes of measurement.

Based on our review of attestation data from Stages 1 and 2 demonstrating provider performance on the CPOE measures, we propose to increase the threshold for medication orders to 80 percent and to increase the threshold for diagnostic imaging orders and laboratory orders to 60 percent.