The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists. The purpose of this publication is to keep our members updated on the NACNS headquarters news; connect our members with fast-breaking clinical news; and update clinical nurse specialists on state and federal legislative actions.

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Featured Headline

  1. Federal Trade Commission Explores Issues in Health Care Market

Headquarters News

  1. National Association of Clinical Nurse Specialists 2014 Annual Conference a Success­­­­­­
  2. 2014 NACNS Series Webinar:  Cutting Edge Information for the Clinical Nurse Specialist
  3. 13th Annual NACNS Summit Scheduled for July 22, 2014 in Washington, DC
  4. 2014 Bylaws Vote Fails to Reach 2/3 Majority Required to Pass
  5. NACNS Membership Survey
  6. 2015 – NACNS Anniversary and Annual Conference

Association News

  1. American Nurses Foundation Announces Grant Opportunities
  2. ANA Reports on APRN Work in Medicare

Clinical News

  1. New Cases of Heartland Virus Disease – a New Emerging Virus
  2. Rate of Autism Now 1 in 68 children
  3. Xstat Approved for Certain Battlefield Wounds

Federal and State Policy News

  1. NACNS Board Votes to Endorse McDermott Bill
  2. Alaska Opens APRN Practice to the Clinical Nurse Specialist
  3. CMS PQRS Reporting for 2014 Impacts Payment
  4. Medicare Physician Payment Rate Increase and ICD-10 Implementation Delayed
  5. CMS Proposed Rules for "General Supervision"

Featured Headline

1. Federal Trade Commission Explores Issues in Health Care Market

The staff of the Federal Trade Commission (FTC) published a policy paper that calls on state legislators to carefully consider the impact of passing legislation that limits the scope of practice of advanced practice registered nurses.  The policy paper, Policy Perspectives:  Competition and the Regulation of Advanced Practice Nurses, notes that by limiting the range of services APRNs may provide and the extent to which they can practice independently, such proposals may reduce competition that benefits consumers.  The policy paper is part of the FTC’s ongoing efforts to promote competition in the health care sector, which benefits consumers through lower costs, better care, and more innovation.

Headquarters News

12. National Association of Clinical Nurse Specialists 2014 Annual Conference a Success

This was one of the best conferences I have attended in a very long time. The subject material was so diverse and exactly what I needed for my practice. Thank you for such an enjoyable experience.” – 2014 NACNS Member and Annual Conference Attendee

The NACNS 2014 Annual Conference was held March 5 – 7 at the Orlando World Center Marriott. There were approximately 525 individuals in attendance. Attendees viewed over 77 posters and a choice of 100 sessions. New this year, participants could apply for Pharmacology CE for sessions that they attended during the main conference that contained pharmacology content. This was in addition to a preconference session that offered 5 CE. 

As a result of our press outreach, HealthLeaders Media ran a preview piece on the conference, highlighting Patti Zuzelo’s, EdD, RN, ACNS-BC, ANP-BC, CRNP presentation on LGBT health disparities.

Social media outreach was also new at this year’s Annual Conference. Ongoing Facebook posts were made highlighting speakers and events. Make sure you join NACNS’ Facebook site. In addition, this year photos from the meeting have been posted on an NACNS Flickr stream. You can sign up to view photos from the conference.

We are excited that so many members attending the meeting! 

3. 2014 NACNS Series Webinar: Cutting Edge Information for the Clinical Nurse Specialist Poised to Launch

You have asked for it and we have heard you! NACNS is poised to open registration on the 2014 NACNS Webinar Series. All webinars are offered at a great deal for NACNS members!

Registration Fees:
Series of 5 Webinars: Members $215 Non Members $280 Student $125
Single Webinar: Member $45 Non Member $60 Student $30.

Times for all sessions: 
3:00 pm eastern/2:00 pm central/1:00 pm mountain/ 12:00 pm west coast

May 21, 2014 - The Value of the Clinical Nurse Specialist (CNS) in Care Coordination
June 18, 2014 - The ABC’s of PQRS
September 24, 2014 - CNS Competencies: Taking the Lead in Clinical Alarm Management
November 12, 2014 3 - The Cutting Edge of Diabetes Management – Pharmacology CE offered
December 10, 2014 - CNS Competencies: Positioning Yourself to Close the Clinical Alarm Gap
To register (registration will open in the coming weeks) – go to  Any questions –

4. The 13th Annual NACNS Summit to be Held on July 22, 2014 in Washington, DC

For the last 12 years, NACNS has provided a forum for leaders from our membership and collegial organizations to come together to discuss clinical nurse specialist hot topic issues. This is a great opportunity for you to directly contribute your opinion to the work of the organization. The meeting is designed to bring subject experts together with NACNS members to discuss the big picture issues facing the clinical nurse specialist. Planning is now underway on the agenda for the meeting – but it is anticipated that we will discuss:

  • the Federal Trade Commission and advanced practice registered nurse (APRN) practice,
  • the challenge of finding DNP programs that offer clinical nurse specialist-oriented education,
  • certification issues for the clinical nurse specialist within in the APRN Consensus Model,
  • and plans to revise the CNS Core Statement.

The meeting is priced to cover the costs of the room rental, catering and speaker expenses. Our annual attendance has been increasing, so we are pursuing a larger meeting room! If you are concerned about the future of the CNS and want your voice to be heard – this is the meeting for you.

Registration will open in on or before the end of April 2014.  For questions, or to pre-register for information on the meeting – email

5. 2014 Bylaws Vote Fails to Reach 2/3 Majority Required to Pass

The NACNS membership was asked to vote on the following Bylaws change brought forward by the NACNS Affiliate and Membership Committees. The final vote taken at the NACNS Annual Meeting and open to online voting resulted in a 52 to 41 vote. A 2/3 majority is needed for a Bylaws vote to pass, therefore this vote failed. The NACNS Board of Directors will continue to look for mechanisms to increase association membership.

6. NACNS Membership Survey

Thanks to all of you who took the time to complete the NACNS Membership Survey. This survey will be used to make decisions about the products and services we can provide our members. In addition, it gives us a good picture of how and where you work and what you are interested in. This year we offered the opportunity for members to be entered into a drawing for a free registration to the NACNS Annual Conference. The winner of the drawing was Debbie Beck from Michigan, an NACNS student member.

7. NACNS 20th Anniversary to be Celebrated in 2015

Yes, it has been 20 years! And the NACNS Board of Directors is planning on recognizing and celebrating our history and success throughout the 2015, but specifically at the NACNS 2015 Annual Conference. This meeting is being held in at the Loews Coronado Bay Resort in San Diego, California. This meeting hotel will allow for an excellent educational experience as well as relaxation and exploration of beautiful Southern California. The hotel offers three pools, a sand beach and a spa. So plan now for a 20th anniversary celebration that will allow you to take care of your mind and body! Plan on submitting a poster, a presentation or encourage your facility to exhibit! 

Visit for details as they become available.

Association News

8. New American Nurses Foundation Grants

The American Nurses Foundation has announced the expansion of our Nursing Research Grants program with the support of $30,000 in funding provided by the American Nurses Credentialing Center to support clinically based research.

The American Nurses Foundation (ANF), established in 1955, is committed to transforming the nation's health through the power of nursing. Central to this mission is the Foundation's Nursing Research Grants program, which encourages rigorous scientific research to advance nursing practice, shape health policy, and impact the health of people across the nation. Since the program's inception over 1,000 nurse researchers have received over $4.5 million in grants to conduct ground-breaking studies that shape and influence nursing practices and play a vital role in launching larger scientific health research.

To support improving the quality of care provided in clinical settings and the integral role nurses play in designing better care, the American Nurses Foundation will increase its funding of studies of systematic, data-guided activities designed to bring about improvement in healthcare delivery, and is soliciting applications from clinical staff through May 1, 2014. The Foundation will award two (2) $5,000 grants to beginning researchers and two (2) $10,000 grants to experienced researchers, with one of each to be awarded to a clinical researcher at a Magnet facility. We invite you to encourage your staff to take advantage of the opportunity to apply for a research award. For more information visit, or contact Gisele Marshall at 301-628-5229.

9. ANA Economist Reports on APRNs’ Participation in Medicare Part B

Peter McMenamin, ANA’s (title) recently reports on the Centers for Medicare and Medicaid Services (CMS) statistics on providers in Medicare Part B. The initial 2012 statistics from CMS indicate that APRNs enrolled as Medicare Part B providers (and billing under their own National Provider Identification (NPIs)) continued to increase their presence in the Medicare program. Total approved charges earned by APRNs increased by 12.7% compared to the increase in approved charges for all Medicare providers of just 1.2%. The 2012 APRN total was over $2.7 billion. APRNs provided one or more services to 11,394,440 Medicare fee-for-service eligible enrollees in 2012.  This was an increase of 1,008,105 persons served compared to the prior year.  Since 2009, there has been a 2% yearly increase for the last for years.

These statistics understate the total provision of APRN services to Medicare patients. They do not include APRN services provided to Medicare Advantage patients. They do reflect APRN services provided in institutional settings and reimbursed under Medicare Part A. And they do not include services provided by APRNs but billed “incident to” physician services under Part B.

Year %# of eligible Medicare Part B beneficiaries that received at least one APRN service Number of Medicare fee-for-service beneficiaries
2009 26% ----
2010 28% ----
2011 30% 10,286,335
2012 32% 11,294,440

According to the statistics reported in the blog written by Peter McMenamin, One Strong Voice there has been an increase in the amount of Medicare approved charges by clinical nurse specialists of 2.4% or a total of $58,189, 376 in 2012. This is above the 1.2% increase for all providers. The largest gains in amount of approved Medicare charges for APRNs is the Nurse Practitioners that saw a 15.5% increase in 2012 and the CNMs that saw a1 13.2% increase in the same year, likely due to the Affordable Care Act’s legislated increase in reimbursement of CNM services to 100% of the physician fee schedule.

CMS continues to expand opportunities for APRNs, including CNSs to directly bill for services. As more CNS step forward and get involved in Medicare reimbursement, we will see the increases in the CNS statistics for percentage of Medicare charges and numbers of Medicare beneficiaries served.

Clinical News

310. CDC Reports More Cases of Heartland Virus Disease

The Centers for Disease Control and Prevention (CDC) in collaboration with health officials in Missouri and Tennessee have identified six new cases of people sick with Heartland virus: five in Missouri and one in Tennessee. The new cases, discovered in 2012 and 2013, are in addition to two discovered in 2009.

Heartland virus was first reported in two northwestern Missouri farmers who were hospitalized in 2009 with what was thought to be ehrlichiosis, a tick-borne disease. However, the patients failed to improve with treatment and testing failed to confirm ehlrlichiosis. Working with state and local partners, CDC eventually identified the cause of the men’s illness: a previously unknown virus in the phlebovirus family now dubbed Heartland virus.

Ongoing investigations have yielded six more cases of Heartland virus disease, bringing to eight the total number of known cases. All of the case-patients were white men over the age of 50. Their symptoms started in May to September and included fever, fatigue, loss of appetite, headache, nausea, or muscle pain. Four of the six new cases were hospitalized. One patient, who suffered from other health conditions, died. It is not known if Heartland virus was the cause of death or how much it contributed to his death. Five of the six new cases reported tick bites in the days or weeks before they fell ill.

Nearly all of the newly reported cases were discovered through a study conducted by the Missouri Department of Health and Senior Services and CDC are actively searching for human cases at six Missouri hospitals.  CDC has been working closely with the Missouri and Tennessee state health departments and other federal agencies to advance understanding of Heartland virus disease by learning more about the patients who were infected, their illness and their exposure to ticks. CDC seeks to determine the symptoms and severity of the disease, where it is found, how people are being infected, and how to prevent infections.

CDC studies to date have shown Heartland virus is carried by Lone Star ticks, which are primarily found in the southeastern and eastern United States. Additional studies seek to confirm whether ticks can spread the virus to people and to learn what other insects or animals may be involved in the transmission cycle. CDC is also looking for Heartland virus in other parts of the country to understand how widely it may be distributed.

CDC developed the blood tests used to confirm the new cases of Heartland virus disease. CDC teams are working to further validate these tests and develop additional tests. As more is learned, CDC hopefully can develop a diagnostic test that public health laboratories could use to test for the virus.

There is no specific treatment, vaccine or drug for Heartland virus disease. Because it is caused by a virus, the disease also does not respond to antibiotics used to treat tickborne bacterial infections such as Lyme disease. However, supportive therapies such as IV fluids and fever reducers can relieve some Heartland disease symptoms.

11. CDC Estimates 1 in 68 Children has Been Identified with Autism Spectrum Disorder

The Centers for Disease Control and Prevention (CDC) estimates that 1 in 68 children (or 14.7 per 1,000 eight-year-olds) in multiple communities in the United States has been identified with autism spectrum disorder (ASD). This new estimate is roughly 30 percent higher than previous estimates reported in 2012 of 1 in 88 children (11.3 per 1,000 eight year olds) being identified with an autism spectrum disorder. The number of children identified with ASD ranged from 1 in 175 children in Alabama to 1 in 45 children in New Jersey.

The surveillance summary report, “Prevalence of Autism Spectrum Disorder among Children Aged 8 Years – Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2010,” was recently published in the CDC’s Morbidity and Mortality Weekly Report. Researchers reviewed records from community sources that educate, diagnose, treat and/or provide services to children with developmental disabilities. The criteria used to diagnose ASDs and the methods used to collect data have not changed.

The data continue to show that ASD is almost five times more common among boys than girls: 1 in 42 boys versus 1 in 189 girls. White children are more likely to be identified as having ASD than are black or Hispanic children.
Levels of intellectual ability vary greatly among children with autism, ranging from severe intellectual challenges to average or above average intellectual ability.  The study found that almost half of children identified with ASD have average or above average intellectual ability (an IQ above 85) compared to a third of children a decade ago. The report also shows most children with ASD are diagnosed after age 4, even though ASD can be diagnosed as early as age 2. Healthy People 2020, the nation’s 10-year health objectives, strive to increase the proportion of young children with an autism spectrum disorder (ASD) and other developmental delays that are screened, evaluated, and enrolled in early intervention services in a timely manner.

CDC’s “Learn the Signs. Act Early.” program has joined with others across the federal government to promote developmental and behavioral screening through the Birth to 5: Watch Me Thrive campaign. This program will help families look for and celebrate milestones; promote universal screenings; identify delays as early as possible; and improve the support available to help children succeed in school and thrive alongside their peers.

Through the Affordable Care Act, more Americans will have access to health coverage and to no-cost preventive services, including autism screening for children at 18 and 24 months. Most health insurance plans are no longer allowed to deny, limit, or exclude coverage to anyone based on a pre-existing conditionExternal Web Site Icon, including persons with autism spectrum disorder. 

12. FDA Allows Marketing for First-of-kind Dressing to Control Bleeding from Certain Battlefield Wounds 

On April 3, 2014 the U.S. Food and Drug Administration (FDA) allowed marketing of an expandable, multi-sponge wound dressing to control the bleeding from certain types of wounds received in battle. For military use only, the XSTAT is a temporary dressing for wounds in areas that a tourniquet cannot be placed, such as the groin or armpit. The dressing can be used up to four hours, which could allow time for the patient to receive surgical care.
According to the U.S. Army Medical Department, Medical Research and Materiel Command, since mid-World War II, nearly 50 percent of combat deaths have been due to exsanguinating hemorrhage (bleeding out). Of those, half could likely have been saved if timely, appropriate care had been available.

The device consists of three, syringe-style applicators containing 92 compressed, cellulose sponges that have an absorbent coating. The sponges expand and swell to fill the wound cavity, after approximately 20 seconds upon contact with water from blood or bodily fluid. This creates a temporary physical barrier to blood flow. The number of sponges needed for effective hemorrhage control will vary depending on the size and depth of the wound. Up to three applicators may be used on a patient. The tablet-shaped sponges are each 9.8 millimeters in diameter and 4 to 5 millimeters in height. They can absorb 3 milliliters of blood or body fluid. An applicator filled with 92 sponges, therefore, can absorb about 300 milliliters of fluid.

The sponges cannot be absorbed by the body and all sponges must be removed from the body before a wound is closed. For ease of visualization and to confirm removal of every sponge, each sponge contains a marker visible via X-ray.

The FDA reviewed XSTAT through its de novo classification process, a regulatory pathway for some novel, low- to moderate-risk medical devices that are first-of-a-kind.  The FDA’s review of the XSTAT submission included animal studies demonstrating its effectiveness at stopping bleeding and the absorption capacity of the device. In addition, non-clinical biocompatibility data and human factors testing were provided to demonstrate the safety and usability of the device.

The XSTAT is manufactured by RevMedX, Inc., in Wilsonville, Ore.

Federal and State Policy

13. NACNS Board Endorses McDermott Bill

The NACNS Board of Directors recently voted to endorse H.R. 3833 introduced on January 9, 2014 by Representative Jim McDermott (D-WA). This bill would amend title XVIII of the Social Security Act to modify the Medicare durable medical equipment face-to-face encounter documentation requirement.  It would allow certain non-physician providers, including physician assistants, nurse practitioners and clinical nurse specialists to document the face-to-face encounter required by the Affordable Care Act. This bill has been referred to the House Committee on Energy and Commerce.

14. Alaska State Board of Nursing Recognizes Clinical Nurse Specialists

This past week we received word that the Alaska State Board of Nursing has added language the state regulations that now recognizes Clinical Nurse Specialists and gives the CNS the ability to practice at an advanced practice registered nurse level. The language was signed by the Lieutenant Governor and is therefore now in place. The Alaska Affiliate is continuing to work with colleague APRN groups to develop additional APRN statutory language that will be introduced next year. The new Alaska regulations are posted on the AK Board of Nursing’s website.
Congratulations to the Alaska State Board of Nursing and the clinical nurse specialists and their APRNs colleagues in Alaska who worked together to make this happen.

15. CMS PQRS Reporting for 2014 Impacts Payment

Individual Eligible Professionals, which includes CNSs, can receive an incentive payment and avoid payment adjustments in 2015 by reporting quality measures one time in the FY 2014. CNSs must satisfactorily report data on quality measures for covered Physician Fee Schedule services furnished to Medicare Part B FFS beneficiaries. For step-by-step instructions on how to implement PQRS, view the How to Get Started Page. The Medicare Website has more information about PQRS. Additional information will soon be available about the 2014 registration process.

16. Medicare Physician Fee Schedule and ICD-10 Implementation “Fixed” in One Bill

On April 1, 2014, President Obama signed the Protecting Access to Medicare Act of 2014. This new law prevents a scheduled payment reduction for physicians and other practitioners who treat Medicare patients from taking effect on April 1, 2014. This new law maintains the 0.5 percent update for such services that applied from January 1, 2014 through March 31, 2014 for the period April 1, 2014 through December 31, 2014. Also included is a zero percent update to the 2015 Medicare Physician Fee Schedule (MPFS) through March 31, 2015.

A surprise to some came in the addition of language that will result in a delay in the implementation date of the nationwide conversion to the ICD-10 diagnostic and procedural codes. The ICD-10 switch was scheduled to occur Oct. 1, 2014. And will now be extended for “a minimum of one year.” It is anticipated that the new date will be October 1, 2015, but CMS will need to announce the new date for compliance. Many facilities were struggling to get the pieces in place to begin the ICD-10 conversion by the original deadline. The bill also includes a collection of changes to Medicare billing and claims processing.

Efforts have been underway in the House and Senate to revise the MPFS. These efforts resulted in a few bills that were introduced that offered alternatives. NACNS worked on these bill options to make sure the clinical nurse specialist was included in these potential revised models of payment. It is anticipated that the passage of the Protecting Access to Medicare Act of 2014 will provide additional time for legislators to consider physician payment reform.

17. CMS Proposed Rules Would Allow APRNS/CNS to Provide Certain Services under “General Supervision”

In the Calendar Year 2012 Hospital Outpatient Prospective Payment System /Ambulatory Surgical Center Final Rule, the Centers for Medicare & Medicaid Services (CMS) established a process to obtain independent advice from the Advisory Panel on Hospital Outpatient Payment (The Panel) regarding the appropriate supervision levels for individual hospital outpatient therapeutic services (76 Fed. Reg. 74360). CMS charged the Panel with recommending at the request of the agency or the public the supervision level that will ensure the appropriate quality and safety for delivery of a given service as defined by its Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology code. In order to make its recommendations, the Panel uses clinical and other criteria that were established in the final rule.

The Panel recommended 18 supervision level changes to CMS. CMS has accepted 6 of the proposed 18 changes.  Specifically, CMS rejected the panel’s recommendation to allow general supervision for eight chemotherapy services, a wound debridement service and two services involving administration of a new drug or substance. CMS also did not accept the panel’s recommendation of general supervision for blood transfusion, but instead proposes to allow extended duration supervision for this service. In addition, the agency seeks clinical input on the appropriate supervision level for initial and subsequent administrations of chemotherapeutic or biological agents provided in hospital outpatient departments, adding that it may reassess these services at the panel’s next meeting.

Services to be provided with general supervision

This proposed rule would allow certain services to be provided with general supervision from physicians, CNSs, NPs, etc. instead of direct supervision; meaning that these services could be provided with the supervising practitioner offsite. The services include the following:

  • G0176, Activity therapy, such as music, dance, art or play therapies not for recreation related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)
  • 36593, Declotting by thrombolytic agent of implanted vascular access device or catheter
  • 36600, Arterial puncture, withdrawal of blood for diagnosis
  • 94667, Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation
  • 94668, Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung   function; subsequent

Services Not to Change from Direct to General Supervision

CMS would not accept the Panel’s recommendation to change the supervision level from direct to general for the following services. These CPT codes describe injection and intravenous infusion of chemotherapy or other highly complex drugs or complex biological agents.

  • 96401, Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic
  • 96402, Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic
  • 96409, Chemotherapy administration; intravenous, push technique, single or initial substance/drug
  • 96411, Chemotherapy administration; intravenous, push technique, each additional substance/drug (list separately in addition to code for primary procedure)
  • 96413, Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug
  • 96415, Chemotherapy administration, intravenous infusion technique; each additional hour (list separately in addition to code for primary procedure)
  • 96416, Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump
  • 96417, Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (list separately in addition to code for primary procedure)
  • 97597, Debridement (eg, high pressure waterjet with/without suction, sharp selective debridementwith scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less .
NACNS will be monitoring this issue and provide comments, as appropriate, in collaboration with the nursing community.

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The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists.
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