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- 1. Definitions and Terminology Jan Mannino, CRNA, JD copyright protected
- 2. • Standardization • Sources of definitions and terminology • Consistency through lectures and writing • Role of the profession to define itself Why? copyright protected
- 3. Categories of Definitions • Practice Status • Reimbursement • Employment copyright protected
- 4. Types of Practice • Independent Practice – Full Practice Authority • Medically Directed • Medically Supervised copyright protected
- 5. Independent Practice • Recognized by statutory law • Common Law Element – Legal cases that validated our practice • Frank v. South • Chalmers Francis v Nelson • Function without direction or collaboration with a physician copyright protected
- 6. Independent Practice • Statutory Law – Nurse Practice Acts – State Health Codes – Federal statutes • Military • VA • Indian Services • CMS (Medicare/Medicaid) copyright protected
- 7. Independent Practice Full Practice Authority Defined as the collection of state practices and licensure laws that allow NPs to: – evaluate, diagnose, order and interpret diagnostic tests, – initiate and manage treatments under the state board of nursing licensing authority (Hain & Fleck, 2014). The term “full practice authority” emphasizes that all health professionals should be allowed to practice to the full extent of their education and training. copyright protected
- 8. Independent Practice • ASSUMPTION IS: CRNA practices to the scope of their education and skills and is not medically directed or supervised. copyright protected
- 9. CRNA/MD Anesthesiologist Collaborative Practice • Does not necessarily involve an employment model • May be only for QA and policy review copyright protected
- 10. NCSBN 2017 copyright protected
- 11. Reimbursement Terminology • Personally Performed – By Independent CRNA or MD Anesthesiologist • Medically Directed – Reimbursement to MDA, who bills under set conditions • Supervised – Part A reimbursement for hospitals to have a policy – Non-opt out states, only copyright protected
- 12. Medicare Terms and Codes • QK Modifier – Medical Direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals copyright protected
- 13. Medicare Terms and Codes • QX Modifier – CRNA service with medical direction by a physician copyright protected
- 14. Medicare Terms and Codes • QY Modifier – Medical direction of a CRNA by an anesthesiologist copyright protected
- 15. Medicare Terms and Codes • QZ Modifiers – CRNA service without medical direction of a physician copyright protected
- 16. Medicare Terms and Codes • GC Modifiers – This service has been performed in part by a resident under the direction of a teaching physician. copyright protected
- 17. Employment Terms* *IRS Definitions • Employed – W-2 tax status • Income and social security taxes withheld • Professionals should have a contract or policies related to benefits of employed status • Employer exerts control over schedules, etc copyright protected
- 18. Employment Terms* • Self-Employed The general rule is that an individual is an independent contractor has control over his work and time. . The earnings of a person who is working as an independent contractor are subject to Self-Employment Tax. * IRS copyright protected
- 19. Self-Employment in CRNA Practice • Private Practice (sole) • Group Practice • Independent Contractor – Locums tenens – Free-lance – Contract for services copyright protected
- 20. Professional Designation A profession is a disciplined group of individuals who adhere to ethical standards. • possessing special knowledge and skills in a widely recognized body of learning derived from research, education and training at a high level, and is recognized by the public as such. • A profession is also prepared to apply this knowledge and exercise these skills in the interest of others copyright protected
- 21. Professionalism Professionalism comprises the personally held beliefs about one’s own conduct as a professional. It’s often linked to the upholding of the principles, laws, ethics and conventions of a profession as a way of practice. copyright protected
- 22. Characteristics of a Profession • Authority and credibility • Community sanction, or regulation and control of its members • Code of ethics • Professional culture, or a culture of values, norms and symbols Greenwood, E. ‘Attributes of a Profession’, Social Work 2, 1957, pp.44- 55. copyright protected
- 23. Other Confusing Terms MAC • Minimum alveolar concentration (Eger) • Monitored Anesthesia Care (reimbursement term that replaced Anesthesia Standby) • Sedation technique the involves an anesthesia professional copyright protected
- 24. Other Confusing Terms Opt-out—is a Medicare Condition of Payment for hospitals, under Part A, requiring a policy for supervision of nurse anesthetists. • States may opt-out of this requirement • It is not a requirement for supervision • It makes no assumptions of vicarious liability • It is no necessary to be in an opt-out state to have an independent practice copyright protected
- 25. Other Confusing Terms Practice of Nurse Anesthesia. • Grammatically incorrect (nurse is a noun, not an adjective) • Inconsistent with professional standards • Recommend: the practice of anesthesiology by CRNAs. copyright protected
- 26. Other Confusing Terms • Provider – It is a reimbursement and insurance term. • Recommend: Professional. Example: Nurse anesthetists are professionals who practice anesthesiology. copyright protected
- 27. Unacceptable Terminology • Mid-level Provider • Physician extender • Nurse (without adding anesthetist) • Anesthesia Nurse (is used in some countries) copyright protected
- 28. Conclusion CRNA Practice Identifiers – Employment • Employed • Self-employed – Reimbursement • Fee for service • Salary • Contracted – Practice Status • Independent • Collaborative or directed copyright protected
- 29. Matrix Employment Status Reimbursement Status Practice Status Employed Salary and benefits Hourly or other Independent or Directed Self-employed Fee for Service Contracted Independent or Directed copyright protected
Editor's Notes
- Welcome to our first lesson in Anesthesia Business Academy. This lesson is part of the Course, Introduction to the Business and Economics of Anesthesia. When setting up both the academy and these courses, it became apparent that there is a lack of consistency in definitions and terminology when it comes in our practice. In order to clarify terms and to make sure we are speaking and writing from the same rule book, we have reviewed the literature, the legal cases, statutes and regulations and have settled on what we are presenting in this course. Also, we are very aware of common terminology, its use and misuse. At the end of this lesson, we will make some recommendations on what we consider to be the best terminology and encourage debate. We are cognizant that some of you may not agree with our interpretation or usage of terms, so let us know your concerns and we will continue the discussion on our Members Only Facebook page and blogs.
- It is unfortunate that we have been late to the table and discussion regarding the definition of nurse anesthesiology practice. Other groups have charged in and have defined us, often in terms inconsistent with actual practice. We believe the AANA, as the primary professional organization representing the needs of nurse anesthetists, should be involved with all outside entities that include us in their policies and discussions. We do not intend to usurp the role of AANA, but will simply try to sort out the various terms for consistency and ease of standardization. There are many organizations, including government agencies, that mention nurse anesthetists in their rules and writings. We have searched most of these organizations, as well as related professional groups and have collated their terminology. We have also used various other government resources, such as CMS, IRS and the Department of Labor. All of us at Anesthesia Business Academy are CRNAs and believe the profession should define itself.
- Since we are focusing on the business of anesthesia, we have not attempted to define categories in anesthesiology education. For now, we will leave that to the program administrators and Council on Accreditation. There are three categories of definitions we will discuss in this course: Practice Status Reimbursement Employment Some of these categories overlap, which adds to confusion. Towards the end of this course, there will be a matrix for you determine where your practice fits.
- For ease of understanding this category, we are referring to the level (if any) of medical direction or supervision in a practice setting. We wish we did not have to use the term “supervision,” because of its connation of someone else controlling our clinical decision making. However, until the term is removed from legislation and reimbursement regulations, we will reluctantly use it. It is the belief of the author (MJM) that a CRNA should graduate from an anesthesiology program able to safely administer anesthesia without physician control or supervision. Anesthesia Business Academy is committed to educating CRNAs and SRNAs on the various practice options, including setting up an anesthesia business. One of the restrictions on this type of practice could be legal or regulatory requirements for some kind of physician oversight.
- We are starting out with one of the most confusing definitions of nurse anesthesiology practice—independent practice. Our practice has been defined by statutory law, especially within the various nursing laws that are determined on a state by state basis. In many states, CRNAs are designated as APNs (Advanced Practice Nurses) and, as such defines the scope of practice, especially as related to direction and/or collaboration with physicians. See map on next slide. In those states where CRNAs are considered as having unrestricted APN status, clearly they meet the definition of Independent Practitioners. However, state laws are not the only rules that determine practice rights. We have good common law rulings that validate the right of nurses to administer anesthesia. Even in the more recent Anti-trust cases, the ability of CRNAs to practice independent of direction or collaboration has been affirmed. FOR THE PURPOSES OF THIS PAPER AND OUR POLICIES, WE DEFINE INDEPENDENT PRACTICE AS FUNCTIONING WITHOUT DIRECTION OR COLLABORATION OF A PHYSICIAN.
- There are a variety of laws and statutes relative to defining CRNA practice and whether or not we can administer anesthesia free of medical direction. In all of the listed statutes, there is confusion about these terms. Currently, the Nurse Practice Acts of most* states define nurse anesthetists and whether or not we are categorized as Advance Practice Nurses. It is advisable for each participant in this course to obtain the relevant information from the states in which you practice. The Federal government has identified our practice in many rules and regulations. Most important, is the definitions in the Medicare reimbursement laws. Regarding direct reimbursement for CRNAs, there is no listed supervision or medical direction requirement. * Pennsylvania and New York are at least two of the states without a clear definition of Nurse Anesthetists in the Nursing Statutes.
- Full practice authority is a rather recent term being promoted by Advance Practice Nursing organizations. Since CRNAs are often included in Advance Practice Nurses laws, there is a lack of national consensus about granting FPA to CRNAs, along with other APNS. This has become a political issue in the on-going debate about full practice authority of APNs in the VA system and in states that do not recognize CRNAs as APNs. FPA was granted to all other APNS, but CRNAs in the Veteran’s system. AANA and AVANA are working diligently to overturn that ruling.
- For the purposes of this course and the philosophy of Anesthesia Business Academy, we make the assumption that a CRNA is a independent practitioner when they practice to the full scope of their education and skills and are not medically directed or supervised. We recognize there are times when another set of “educated hands” is necessary and appropriate in clinical practice. However that help may be another CRNA, a surgeon, an RN and does not need to be an MD anesthesiologist.
- We must recognize there are many hybrids of practice models in our profession. Another one may be a CRNA/MD Anesthesiologist collaborative model. In these practices, there is not employment relationship between the two professions. Rather there could be a mutually respectful relationship where an MD Anesthesiologist may review medical records for quality assurance. That person may also be involved in reviewing policies in an anesthesia department. These collaborative models usually rely on a hospital or facility to pay for the services of such an anesthesiologist.
- The National Council of State Boards of Nursing has determined the states where CRNAs can practice independently. These determinations are based on license requirements of each state.
- Terminology that has been adopted by healthcare reimbursement organizations, including Medicare goes a different direction from clinical practice. Because Medicare has essentially three different models for reimbursement of anesthesia fees, these categories further define our practice. The next slides will discuss the various modifiers that are used on billing forms to indicate the type of billing and reimbursement from Medicare.
- QK Modifier--Qualified individuals include CRNAs and Anesthesiology Assistants, interns or residents.
- QX Modifier- CRNA Service with medical direction by a physician
- QY Modifier – Medical Direction of a CRNA by an MD Anesthesiologist
- QZ Modifier – CRNA Service without medical direction of a physician
- GC Modifiers Service has been performed, in part by resident under the direction of a teaching physician
- The Internal Revenue Service (IRS) has set the standard for employment terminology and it is quite simple. One is either employed or self-employed. According to the IRS, one is EMPLOYED or a W-2 Status, when income and social security taxes are withheld by employer. The other key component of defining the employment status is control. If a person is employed, the employer exerts control of schedules, working conditions, and related policies. It is important for CRNAs to understand that they are exempt from labor laws and for that reason they should expect their employment rights to be described in a written contract and policies.
- If one does not meet the criteria of an employed (W-2) status, the other option is Self-employment. Many CRNAs refer to this as 1099 status. 1099 refers to the IRS criteria for reporting income and which taxes and social security are not withheld. Since taxes are not withheld, the CRNA who functions in this model, is required to pay self-employment taxes and quarterly income taxes. Most critical to the determination of whether or not one is employed or self-employed (independent Contractor) is the issue of CONTROL.
- Self-employment models for CRNAs encompass several types of practice. One may be a sole provider in their own practice. Or the may be part of a group practice of all sole providers. The legal and tax term most frequently used in the self-employment model is Independent Contractor. In the CRNA world, various other terms have been used in the Independent Contractor model, including, locums tenens, free-lance or contracted services. No matter what terminology is used, the IRS requirement are the same. No taxes are withheld, so the individual is responsible for their own tax obligations. The issue of control is again the determining factor.
- When defining nurse anesthetists, we must never lose sight of the fact that we are considered professionals. While others try to reduce us to technicians, we meet all of the criteria of a learned profession. As the professional organization for nurse anesthetists, AANA has developed a Code of Ethics, which meets one of the primary identifiers of a profession. Through the Council of Accreditation of Nurse Anesthesia Programs, CRNAs are required to be educated in rigorous academic and clinical settings. Our programs are publically recognized by the US Department of Education and by most states in nursing laws. The anesthesia care delivered to patients by CRNAs is consistent with the application of knowledge and skills to the care of patients. We bring the nursing perspective of vigilance and patient advocacy to anesthesia care.
- The National Boards of Certification and Recertification of Nurse Anesthetists (NBCRNA) further promotes professionalism in setting criteria for certification and recertification. They recognize that professionals must keep current in practice standards and tie that in to a recertification process.
- The characteristics of a profession have been defined by many. CRNAs fit the characteristics as defined by Greenwood. Clearly, we have respect and credibility in the healthcare arena. In recent years with the proliferation of social media and various continuing education endeavors, CRNA culture of values and norms are apparent. We are passionate about our patients, our profession and values.
- Moving on from standard terminology related to employment models and practice characteristics, there are other terms that are confusing to not only, our profession, but to others who comment on our practice. One of the most confusing is the acronym MAC. It has gone form a pharmacologic term as defined by Eger as Minimum Alveolar Concentration of anesthetic agents to a billing term. Monitored Anesthesia Care (MAC) has been defined by Medicare as a modifier that allows for payment of an anesthesia professional, when they are involved with a procedure that does not involve general anesthesia In future lectures, we will discuss the history of this term and make recommendations on how it should be used.
- One of the most confusing and poorly understood terms is Opt-out. The only definition that should be used is that from the Medicare Part A manual. Part A refers to HOSPITAL reimbursement and has nothing to do with direct Part B reimbursement for anesthesia services by CRNAs. The Medicare manual has listed the requirement for a hospital to have a POLICY on supervision of nurse anesthetists. There are not specific recommendations for what should be in that policy, so a hospital may have a simple statement about a mechanism for such. The reality is –this is only a requirement for a policy and does not define supervision or assumes any vicarious liability. If a state wishes, they can OPT-OUT of this requirement. Whether or not a state has opt-ed out of this policy, has nothing to do with the right of a CRNA to function in an independent, self-employed model or to bill for services performed.
- There is a movement to change our designation to “nurse anesthesiologist” instead of the more difficult to pronounce and confusing, “nurse anesthetist.” Anesthesia Business Academy will not take a stand on that movement, at this time but strongly suggest that we use the better term of “practice of anesthesiology by CRNAs,” or some similar phrase. The suffix …ology means the study of and clearly, CRNAs study anesthesia – thus anesthesiology.
- Some terms are defined by others than the profession. One that the insurance industry has utilized is “provider.” We suggest that in discussing clinical, academic and research in conversations and literature, the term “provider” be replaced by “professional.” For example: Nurse anesthetists are professionals who practice anesthesiology, Or, Anesthesia professionals are advised to….
- While some other defining terms may be used by others, we find them unacceptable and hope their use will disappear form any lexicon regarding CRNAs. Unfortunately, Medicare uses the term “Mid-level provider” to define non-physicans. Other defining terms go from inaccurate to demeaning. As professionals, we have the right and obligation to define our profession and to call attention to unacceptable terminology
- For purposes of these lectures and to have some standard terminology, we have divided CRNA Practice Identifiers into three categories, based on Employment, Reimbursement and Practice Status. These terms may be different from what other groups use, but we are basing ours on legal definitions and common terminology.
- This final slide is a matrix that pulls together the terms used in this lecture. A CRNA or SRNA should be able to slot themselves in at least two of these categories.