Take Action Now: Ensure NPs Ability to Order Portable X-Ray Services

Overview

The ability for nurse practitioners to order portable x-ray services for diagnosis and treatment of a wide range of conditions is crucial to the timely, cost-efficient delivery of appropriate care for Medicare beneficiaries. Yet conflicting and confusing interpretation of current regulations has resulted in the denial of payment for services ordered by NPs and other qualified non-physician providers.

Medicare recently proposed new regulations that would clearly authorize payment for portable x-ray services ordered by nurse practitioners. These regulations are not final - they are open for public comment until September 4. It is important for nurse practitioners to support the proposed regulations.

Denial of Portable X-Ray Services Ordered by Nurse Practitioners

Even though the Medicare program recognizes the authority of nurse practitioners to order diagnostic x-rays, conflicting rules have limited Medicare payment for portable x-ray examination to those "performed only on the order of a doctor of medicine or doctor of osteopathy licensed to practice in the State (42 CRF § 486.106). A December 2011 report by the Department of Health and Human Services (HHS) Office of Inspector General on "Questionable Billing Patterns of Portable X-Ray Suppliers" (OEI-12-10-00190) highlighted concerned about portable x-ray services ordered by non-physician providers. The Centers for Medicare and Medicaid Services (CMS) is currently attempting to recover from home health agencies payments for portable x-ray services ordered by non-physicians that are now considered errors.

ACNP and other NP organizations met with CMS staff in May to explain the problem and ask for immediate action to correct the policy.

Corrective Regulations

CMS proposed regulations July 6 to clarify that Medicare will cover and pay for portable x-ray services ordered by nurse practitioners. Specifically, the proposed rule says:

"We propose to revise our current regulations...to allow other physicians and nonphysician practitioners acting within the scope of their Medicare benefit and State law to order portable x-ray services..."

"This proposed change would allow a MD or DO, as well as an nurse practitioner, clinical nurse specialist, physician assistant, certified nurse-midwife, doctor of optometry, doctor of dental surgery and doctor of dental medicine, doctor of podiatric medicine, clinical psychologist, and clinical social worker to order portable x-ray services within their State scope of practice and the scope of their Medicare benefit."

Portable X-Ray Services Ordered on the Same Day as Clinical Services

In proposing the new regulations, CMS also expresses its concern about questionable billing patterns, specifically the delivery of portable x-ray services on the same day that a patient also receives services in a clinical setting such as a hospital or practitioner's office. Although current rules require an explanation of why the patient's condition requires portable x-ray services, the agency questions whether such services are necessary:

"Under our current regulation at §486.106(a)(2), the order for portable x-ray services must include a statement concerning the condition of the patient which indicates why portable x-ray services are necessary. If the patient was able, on the same day that a portable x-ray service was furnished, to travel safely to a clinical setting, the statement of need for portable x-ray services could be questionable."

Help CMS Understand The Importance of Ordering Portable X-Ray Services in NP Practice

The new Medicare regulations are not final - they could be weakened unless CMS hears from you and your colleagues how important the ordering of portable x-ray services is to your patients and practice. Agency officials also need clear examples demonstrating the appropriate use of portable x-ray services to care for Medicare patients, including situations in which portable x-ray services may be appropriately required on the same day other services are provided in a clinical setting. It is critical that CMS officials get an accurate understanding of how portable x-ray services contribute to the ability of nurse practitioners to provide the best care for their patients.

Submitting Your Comments

The most simple and effective way to submit comments on a proposed regulation is directly through the federal government's website at Regulations.gov. Click www.regulations.gov and follow the instructions for "submitting a comment" to proposal "CMS-1590-P."

If you prefer to submit comments by mail, please be sure to reference ""CMS-1590-P" as noted below. Mailed comments must be received at CMS by 5 pm on September, 2, 2012, so please allow sufficient time for mailed comments to be delivered before the deadline. Comments may be mailed to:

Centers for Medicare & Medicaid Services

Department of Health and Human Services

Attention: CMS-1590-P

P.O. Box 8013

Baltimore, MD 21244-8013

ATTN: CMS-1590-P

Talking Points

In your own words and using your own experience and examples:

1. Support the proposed change in Medicare regulations clearly authorizing coverage of and payment for portable x-ray services ordered by nurse practitioners.
2. Provide examples of how you use portable x-ray services to provide more timely appropriate care for Medicare patients.
3. Explain how limiting the ordering of these services to only physicians interferes with patient care and increases Medicare's costs.
4. Provide examples of situations in which portable x-ray services are appropriately provided on the same day as other services in clinical settings, how commonly these situations arise, and how current documentation requirements should be sufficient to validate that services are appropriate, and problems that could be caused by restricting same-day portable x-ray and clinical services.

So that we can track the number of comments to CMS on this issue, please be so kind as to email a copy of your letter to DAVID@ACNPWEB.ORG.