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. CMS Issues Guidance on Transitional Care Billing

Headquarters News

  1. July 21, 2014 – Dates for Clinical Nurse Specialist Educators’ Forum
  2. July 22, 2014 – Date for 13th Annual NACNS Clinical Nurse Specialist Summit
  3. 2014 NACNS Series Webinar: Cutting Edge Information for the Clinical Nurse Specialist
  4. Coming Soon – Clinical Nurse Specialist Census
  5. 2015 – NACNS Anniversary and Annual Conference

Association News

  1. ANA – Code of Ethics – Comments Requested

Clinical News

  1. New Disease Alert! - MERS Coronavirus – Cases Now Seen In U.S.
  2. More than 50% of Adults Use at Least One Prescription Drug

Federal and State Policy News

  1. Minnesota Legislation Promotes Practice of Advanced Practice Registered Nurses including the Clinical Nurse Specialist
  2. CMS Burden Reduction Final Rule on Regulatory Burden Reductions Published
  3. Bureau of Labor Statistics, Standard Occupational Classification, Federal Register Notice Published

Featured Headline

1. Centers for Medicaid and Medicare Services Published Guidance on Billing for Transitional Care

CMS Information on Transitional Care Management (TCM) Services

1The Centers for Medicare and Medicaid Services (CMS) has developed information about billing transitional care management services (TCM). (Link to pdf on NACNS web page). The clinical nurse specialist (CNS) is eligible to bill for these services. The requirements for a service to be considered under the TCM billing include services that are required during the beneficiary’s transition to the community setting following particular kinds of discharges. The health care professional – the CNS is eligible to be considered in this role – accepts care of the beneficiary post-discharge from the facility setting without a gap and takes responsibility for the beneficiary’s care. The beneficiary must have medical and/or psychosocial problems that require moderate or high complexity medical decision making. The 30-day TCM period begins on the date the beneficiary is discharged from the inpatient hospital setting and continues for the next 29 days.

There are two CPT codes assigned for use in billing TCM. They include CPT Code 99495 – Transitional care management services with moderate medical decision complexity (face-to-face visit within 14 days of discharge); or CPT Code 99496 – Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge). The face-to-face visit is part of the TCM service and is not reported separately.

The Clinical Nurse Specialist is an eligible provider for these services if they are legally authorized and qualified to provide the services in the State in which the services are furnished. Other providers potentially include: physicians (any specialty); certified nurse-midwives; nurse practitioners; and physician assistants.

TCM services are furnished following the beneficiary’s discharge from one of the following inpatient hospital settings:

  • Inpatient Acute Care Hospital;
  • Inpatient Psychiatric Hospital;
  • Long Term Care Hospital;
  • Skilled Nursing Facility;
  • Inpatient Rehabilitation Facility;
  • Hospital outpatient observation or partial hospitalization; and
  • Partial hospitalization at a Community Mental Health Center.

Following discharge from one of the above settings, the beneficiary must be returned to his or her community setting, such as:

  • His or her home;
  • His or her domiciliary;
  • A rest home; or
  • Assisted living.
During the 30 days beginning on the date the beneficiary is discharged from a hospital inpatient setting, the following three TCM components must be furnished; an interactive contact; certain non-face-to-face services; and a face-to-face visit. Additional information on the specifics of this important billing opportunity can be found on the CMS website.

Headquarters News

2. June 21, 2014 – Clinical Nurse Specialist Educators’ Forum

NACNS is pleased to announce a new meeting - NACNS Clinical Nurse Specialist Educators’ Forum - is being held in conjunction with the 13th Annual NACNS Clinical Nurse Specialist Summit (see below) on Monday, July 21, 2014 in Washington, DC. This meeting is intended to provide an opportunity for clinical nurse specialist faculty to discuss issues of concern to them as they work to address the changing world of clinical nurse specialist practice. It is intended to be a brainstorming time – an opportunity to learn from each other and help refine our efforts to what is most helpful for our clinical nurse specialist educators and students.

We are pleased the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) has offered their conference room for this meeting Because of space considerations, we will need to limit registration for this meeting to about 25 people. While the agenda is still being developed we suspect the meeting will be held from about 1:30 pm – 5:30 pm. Participants must register, but there is no fee for the July 21, 2014 meeting. To register, please contact info@nacns.org.

3. June 22, 2014 – 13th Annual NACNS Clinical Nurse Specialist Summit

13th Annual NACNS Clinical Nurse Specialist Summit will be held on Tuesday, July 22, 2014 in Washington, DC. NACNS is hosting its CNS Summit at a conference room in the National Center for Higher Education building where the American Association of Colleges of Nurses has their offices, One Dupont Circle, NW Washington, DC 20001. Due to the size of the conference room, we will have a limit of 60 participants, so please let us know as soon as possible if you are interested in attending. There is a modest fee of $95.00 for this program. The Summit will be scheduled for one-day convening at 9:00 am and adjourning at 5:00 pm on July 22rd. The 13th Annual NACNS Clinical Nurse Specialist Summit will be focused on a discussion of the issues that the clinical nurse specialist faces with the implementation of health care reform and the continued implementation of the APRN Consensus Model. A draft agenda is available on the NACNS web site. Please note, this agenda is subject to change. Please note, new this year is the NACNS Clinical Nurse Specialist Educators’ Forum (see above). The Forum will be held on Monday, July 21, 2014 at a nearby location.

In the past, NACNS held the Summit as an annual invitational meeting for specialty nursing organizations representing CNSs, nursing leaders and other colleague organizations. The agenda for these meetings was designed to gather input from these important constituents to help the NACNS leadership adopt priorities for the Association. In 2012, NACNS changed the Summit to allow for open registration from the NACNS membership and other constituents. Due to space limitations please make sure you reserve your place early. We are accepting responses until June 30, 2014. More information, including a registration form is available on the NACNS website. You may also email Jason Harbonic at info@nacns.org to register or ask questions.

4. 2014 NACNS Series Webinar: Cutting Edge Information for the Clinical Nurse Specialist – Register for Next Session!!

The ABC’s of PQRS (Physician Quality Reporting System) and other Upcoming Webinars – June 18, 3:00 pm EST

The kickoff of the NACNS Webinar Series: Cutting-Edge Information for the Clinical Nurse Specialist was a success and we are now preparing for our second NACNS Webinar topic – The ABC’s of PQRS – June 18, 2014 3:00 pm EST.* 1.0 Contact hours will be awarded for this webinar.

This educational session is designed to assist clinical nurse specialists (and other APRNs) to understand the basics of the Center’s for Medicare and Medicaid (CMS) PQRS system and how to get involved. Clinical nurse specialists are eligible for this important federal program!

We were able to secure a speaker from CMS, Sophia Autrey, a Social Science Research Analyst who will join Pamela Mittelstadt, MA, RN an NACNS public policy consultant in providing this important program for you.

The program objectives:

At the conclusion of this session, the learner should be able to:

  • Describe PQRS,
  • Discuss the quality measures included in PQRS
  • Identify how you can become enrolled in PQRS

If you want to preview some information on this program, go to the Medicare Website and view the How to Get Started Page. Additional information will soon be available about the 2014 registration process.

Registration Fees:
Single Webinar: Member $45 Non Member $60 Student $30. To register – go to www.nacns.org. Any questions – info@nacns.org

Upcoming Dates and Topics for Future Webinars:
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

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

* 1.0 Contact hours will be awarded for this session.

This continuing nursing education activity was approved by the PA State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Criteria for successful completion includes attendance at minimum, of one session during the NACNS Annual Meeting and submission of a completed CE tracker triplicate form to the registration desk prior to the end of the conference. The planning committee members and speakers have declared no conflict of interest. Approval of the continuing education activity does not imply endorsement by the provider, ANCC or PA State Nurses Association.

5. Coming Soon – Clinical Nurse Specialist Census

With the retirement of the Health Resources and Services Administrations national nurse survey, the responsibility for data collection has been shifted to the states and other entities. NACNS has continued to assess the practice and interests of our membership through our NACNS member survey. We recently completed another round of this survey in fall 2013. Being concerned about the lack of national-level information about the CNS role, NACNS will be launching a CNS Census. This surveymonkey-style tool is designed to capture demographic, practice and education data on those that complete the survey. Different from the NACNS member survey, we will be partnering with other organizations and will ask our members to forward the link for the CNS Census to any and all CNSs that you know. We want to hear from as many individuals that identify themselves as CNSs and/or were educated as CNSs. We are less interested in their current, specific job title. We want to see how those with CNS education and experience are contributing to the health care system. Results of the CNS Census will be published in the Clinical Nurse Specialist: The International Journal for Advanced Nursing Practice. It is hoped that the CNS Census will be opened for data collection in early June. Please watch your email, the NACNS website and future newsletters.

6. Celebrate the NACNS 20th Anniversary 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. The theme for this meeting is, “The Clinical Nurse Specialists: The Essence of Transitional Health Care.” This meeting is being held 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! The Loews Coronado Bay Resort caters to relaxation and will allow all of us to learn, network and relax. Coronado Island is a 10 minute cab ride from downtown San Diego. This will give everyone the best of both worlds – shopping and restaurants in San Diego and pampering and beautiful views on Coronado Island. Do consider extending your trip by a day to appreciate the beauty of this area.

Plan on submitting a poster, a presentation or encourage your facility to exhibit! We have intentionally moved the dates for session/presentation and poster applications to earlier in the year. This will allow the planning committee more time to review and select your submissions.

Association News

7. ANA Code of Ethics

ANA Wants to Hear from You: Call for Public Comment - ANA Code of Ethics with Interpretive Statements

Why is having a Code of Ethics so important? Let Margaret Ngai, BSN, RN, a member of the Oregon Nurses Association explain: “The importance of having a Code of Ethics that is accessible and applicable to every nurse cannot be overstated. I am honored and grateful to have been given the opportunity to be included in this important work of the revision panel that will surely shape and guide our profession for years to come.” The revised Code of Ethics for Nurses with Interpretive Statements, a foundational document for RNs and APRNs, is now open for public comment. We encourage you to read the revised document in its entirety before posting your comments. This will help with understanding the flow and how the content is arranged under the preface and nine provisions. The comment period closes June 6, 2014.  Click here to access the public comment space. Thank you in advance for your comments. Questions? Email professionalissuespanels@ana.org.


Clinical News

38. CDC Reports Imported Cases of Middle East Respiratory Syndrome (MERS) in the U.S.

On May 12, 2014, the Centers for Disease Control and Prevention (CDC) reported that a second imported case of Middle East Respiratory Syndrome (MERS) was confirmed in a traveler to the United States. This patient is a healthcare worker who resides and works in Saudi Arabia. This case is unlinked to the first U.S. imported case of MERS reported May 2 in Indiana. Despite this second imported case, the risk to the U.S. general public from MERS still remains very low. Both imported MERS cases are healthcare workers who recently worked in and traveled from Saudi Arabia.

On May 1, the patient traveled by plane from Jeddah, Saudi Arabia to London, England, to Boston, Massachusetts, to Atlanta, Georgia, and to Orlando, Florida. The patient reported feeling unwell during the flight from Jeddah to London and continued to feel unwell on subsequent flights with reported symptoms that include fever, chills and a slight cough. On May 9, the patient went to the emergency department of a hospital in Florida and was admitted the same day. The patient is isolated, being well cared for, and is currently doing well.

Because of the patient’s symptoms and travel history, the Florida Department of Health officials tested the patient for MERS Coronavirus (MERS-CoV), the virus that causes MERS. Those tests were positive, and CDC confirmed MERS-CoV infection in the patient.

“Given the dramatic increase in MERS cases in the Arabian Peninsula, we expected and are prepared for additional imported cases,” said Dr. Anne Schuchat, assistant surgeon general and director of CDC’s National Center for Immunizations and Respiratory Diseases. “The reason for this increase in cases is not yet known, but public health investigations are ongoing, and we are pleased to have a team in Saudi Arabia supporting some of those efforts.”
CDC and Florida health officials are not yet sure how the patient became infected with the virus. Exposure may have occurred in Saudi Arabia, where outbreaks of MERS-CoV infection are occurring. Officials also do not know at this time exactly how many people had close contact with the patient.

Federal, state, and local health officials are taking action to minimize the risk of spread of the virus. The hospital is using standard, contact, and airborne isolation precautions, to avoid exposure to MERS-CoV within the hospital.

As part of the prevention and control measures, officials have begun reaching out to healthcare professionals, family members, and others who had close contact with the patient to provide guidance about monitoring their health and recommending they see a healthcare provider for an evaluation. Public health officials are working with airlines to identify and notify U.S. travelers who may have been in close contact with the patient on any of the flights.

“The rapid identification and response to this case are a reflection of all of the work that CDC and partners have done over the past two years to prepare for MERS entering the United States,” said Schuchat

All reported cases of MERS have been linked to countries in the Arabian Peninsula. In some instances, the virus has spread from person to person through close contact, such as caring for or living with an infected person. However, there is currently no evidence of sustained spread of MERS-CoV in community settings. “The risk to the U.S. general public from MERS still remains very low,” said Schuchat.

While experts do not yet know exactly how this virus is spread, CDC advises Americans to help protect themselves from respiratory illnesses by washing hands often, avoiding close contact with people who are sick, avoiding touching their eyes, nose and/or mouth with unwashed hands, and disinfecting frequently touched surfaces.

At this time, CDC does not recommend anyone change their travel plans. CDC advises people traveling to the Arabian Peninsula who work in a healthcare setting to follow CDC’s recommendations for infection control. Other travelers to the Arabian Peninsula should take general steps to protect their health. Anyone who develops fever and symptoms of respiratory illness, such as cough or shortness of breath, within 14 days after traveling from countries in or near the Arabian Peninsula should call ahead to a doctor and mention their recent travel.

Background
Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is a virus that is new to humans and was first reported in Saudi Arabia in 2012. So far, including this U.S. importation, there have been 538 confirmed cases of MERS in 14 countries. Most of these people developed severe acute respiratory illness, with fever, cough, and shortness of breath; 145 people died. Officials do not know where the virus came from or exactly how it spreads. There is no available vaccine or specific treatment recommended for the virus. 
For more information about MERS-CoV, please visit:

9. The Importance of the Patient History – Approximately 50% of Adults Use at Least One Prescription Drug

About half of all Americans reported taking one or more prescription drugs in the past 30 days during 2007-2010, and 1 in 10 took five or more, according to Health, United States, 2013, the government’s annual, comprehensive report on the nation’s health. The most common prescription drugs among adults are those for cardiovascular disease and high cholesterol.

This is the 37th annual report prepared for the Secretary of the Department of Health and Human Services by the Centers for Disease Control and Prevention’s National Center for Health Statistics. The report includes a compilation of health data from state and federal health agencies and the private sector.

This year’s report includes a special section on prescription drugs. Key findings include:

  • About half of all Americans in 2007-2010 reported taking one or more prescription drugs in the past 30 days. Use increased with age; 1 in 4 children took one or more prescription drugs in the past 30 days compared to 9 in 10 adults aged 65 and over.
  • Cardiovascular agents (used to treat high blood pressure, heart disease or kidney disease) and cholesterol-lowering drugs were two of the most commonly used classes of prescription drugs among adults aged 18-64 years and 65 and over in 2007-2010. Nearly 18 percent (17.7) of adults aged 18-64 took at least one cardiovascular agent in the past 30 days.
  • The use of cholesterol-lowering drugs among those aged 18-64 has increased more than six-fold since 1988-1994, due in part to the introduction and acceptance of statin drugs to lower cholesterol.
  • Other commonly used prescription drugs among adults aged 18-64 years were analgesics to relieve pain and antidepressants.
  • The prescribing of antibiotics during medical visits for cold symptoms declined 39 percent between 1995-1996 and 2009-2010.
  • Among adults aged 65 and over, 70.2 percent took at least one cardiovascular agent and 46.7 percent took a cholesterol-lowering drug in the past 30 days in 2007-2010. The use of cholesterol-lowering drugs in this age group has increased more than seven-fold since 1988-1994.
  • Other commonly used prescription drugs among those aged 65 and older included analgesics, blood thinners and diabetes medications.
  • In 2012, adults aged 18-64 years who were uninsured for all or part of the past year were more than four times as likely to report not getting needed prescription drugs due to cost as adults who were insured for the whole year (22.4 percent compared to 5.0 percent).
  • The use of antidepressants among adults aged 18 and over increased more than four-fold, from 2.4 percent to 10.8 percent between 1988-1994 and 2007-2010.
  • Drug poisoning deaths involving opioid analgesics among those aged 15 and over more than tripled in the past decade, from 1.9 deaths per 100,000 population in 1999-2000 to 6.6 in 2009-2010.
  • The annual growth in spending on retail prescription drugs slowed from 14.7 percent in 2001 to 2.9 percent in 2011.
Health, United States, 2013 features 135 tables on key health measures through 2012 from a number of sources within the federal government and in the private sector.  The tables cover a range of topics, including birth rates and reproductive health, life expectancy and leading causes of death, health risk behaviors, health care utilization, and insurance coverage and health expenditures. 

Federal and State Policy

10. Minnesota Legislation Promotes Practice of Advanced Practice Registered Nurses including the Clinical Nurse Specialist

On May 1, 2014, the Minnesota Coalition of APRNs negotiated and saw passed bill S. F. 511. The final bill passed represented a compromise deal with the physician opposition in Minnesota. The bill was passed by the Minnesota House Floor on May 8th and signed into law by Governor Dayton on May 13, 2014.

According to bill supporters, the main parts of their legislation remained intact and all four roles of APRNs have autonomous practice and prescriptive authority effective January 1, 2015. The negotiated aspects of this legislation are that:

  1. new graduate NPs and CNSs will need to practice under a collaborative agreement (not written) with an APRN or physician in a clinical system that includes physicians and APRNs for the first 2080 hours (1-year full-time) of practice
  2. CRNAs will need to practice under a collaborative agreement (not in writing) only when treating patients for non-perioperative, non-procedural, or non-obstetrical acute or chronic pain conditions and will need to maintain a written prescriptive agreement for prescribing to treat chronic pain.

In addition, an APRN Advisory Committee for the Board of Nursing that will include 4 APRNS (one for each role), 2 physicians appointed by the Board of Nursing, and one public consumer. The advisory committee will be chaired by an APRN and will review practice trends, prescribing and complaint data in the aggregate, and advice the Board of Nursing on emerging practice. The committee will not view individual data nor will it have any regulatory authority.

11. CMS Burden Reduction Final Rule on Regulatory Burden Reductions Published

CMS issued its burden reduction final rule on regulatory burden reductions. NACNS along with the APRN Workgroup submitted comments in April 2013 urging CMS to eliminate unnecessary requirements for physician supervision of APRN services. The final rule addresses supervision in hospitals, Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs), and who can be distant health provider of telehealth services.

Hospital Medical Staff - The final rule states that the medical staff must be composed of doctors of medicine or osteopathy and that in accordance with State law, including scope-of-practice laws, the medical staff may also include other categories of physicians and non-physician practitioners who are determined to be eligible for appointment by the governing body. This allows for other types of non-physician practitioners (such as Advanced Practice Registered Nurses (APRNs), Physician Assistants (PAs), Registered Dietitians (RDs), and Doctors of Pharmacy (PharmDs)) to be included on the medical staff.

Supervision in CAHs - CMS has eliminated the need for physicians to review every two weeks and sign a sample of outpatient records of patients cared for by nurse practitioners, clinical nurse specialists, certified nurse midwives, or physician assistants. Instead this can be done “periodically” as determined by the CAH.

Supervision OP CAH Services- Outpatient services provided “incident to” in CAHs can be supervised by a non-physician practitioner (clinical nurse specialist, clinical psychologist, licensed clinical social worker, physician assistant, nurse practitioner, or certified nurse-midwife), if they are qualified to supervise the service. The service must have direct supervision (onsite) and the physician or non-physician practitioner must be immediately available to furnish assistance and direction for the duration of the service.

CMS discussion about supervision beyond the scope of the proposal - Medicare coverage rules arbitrarily determine which “physician” services are restricted to doctors of medicine and osteopathy only and which are permissible for nurse practitioners, clinical nurse specialists and other APRNs to provide. CMS stated that some commenters recommended that nurse practitioners should be included in the definition of “physician” or listed with physicians as a qualified provider wherever the terms “physician” or “physician services” are used. CMS said that while this is beyond the scope of the rule, they will consider these suggestions for future rulemaking.

Telehealth -The rule finalized the proposal that clinical nurse specialists, physicians, nurse practitioners, physician assistants and certified nurse midwives can be distant site providers (practitioners furnishing covered telehealth services) when they are not employed by an FQHC or RHC. RHCs that are located in rural Health Professional Shortage Areas (HPSAs), or in counties outside of Metropolitan Statistical Areas (MSA), are authorized by law to be telehealth-originating sites (the location of an eligible Medicare beneficiary at the time the service is furnished via a telecommunications system).

Source: Centers for Medicare & Medicaid Services, 42 CFR Parts 413, 416, 440, 442, 482, 483, 485, 486, 488, 491, and 493, Medicare and Medicaid Programs; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction; Part II 

12. Bureau of Labor Statistics Publishes Federal Register Notice Regarding 2010 Standard Occupational Classification Development Process – Comments Requested 

On May 22, 2014, the Bureau of Labor Statistics rulemaking regarding the 2010 Standard Occupational Classification.  The Standard Occupational Classification when published in 2004 included 3 of the 4 APRN categories as separate from the registered nurse.  The clinical nurse specialist role was not included with the other three roles, CNM, NP and CRNA. 
The publication of this rulemaking will allow NACNS and other organizations to comment on current occupational categories and specifically allow us to advocate for the inclusion of the clinical nurse specialist role as one of the 4 APRNs for purposes of the standard occupational classification.

NACNS was anticipating the publication of this rulemaking and will be finalizing our comments to the Department of Labor Statistics.  We will be working with other organizations to support the CNS role as one of the 4 APRN roles as well as providing model comments for interested members to submit.  The deadline for submission is July 21, 2014.

This is a publication of the National Association of Clinical Nurse Specialists. You are receiving this publication because you are identified as holding a membership in NACNS. If you wish to unsubscribe from this publication, please email info@nacns.org. Please note, if you unsubscribe, this will remove you from all email communications from NACNS.
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The CNS Communiqué is an electronic publication of the National Association of Clinical Nurse Specialists.
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