Recent News

Please see common questions and answers below to questions in these categories:

 

Prescriptive Authority & Controlled Substances

 Quality Assurance

Hiring an Advanced Practice Nurse

Performing Procedures

Ordering Home Health/Durable Medical Equipment/Diabetic Shoes

Death Certificates

Delegation

Concussion

Reimbursement

Collaboration

 

1.  PRESCRIPTIVE AUTHORITY AND CONTROLLED SUBSTANCES

Q: My collaborating physician has a Suboxone practice. While he was on vacation, he asked me to phone in a refill for a patient who lost his prescription for the Suboxone. Can I call in this prescription?

A: Suboxone is a schedule III drug which listed on the Ohio Board of Nursing formulary as “CTP holder may not prescribe”. Therefore the Advance Practice Registered Nurse (APRN) with a Certificate to Prescribe (CTP) may not call this drug in under his/her name. However, the APRN may act as a prescriber’s agent and call the medication in to the pharmacy under the collaborating physicians name and authorization. The NPI number and DEA number would therefore be those of the collaborating physician.

To view the current formulary:  http://www.nursing.ohio.gov/PDFS/AdvPractice/5-20-13_Formulary_6_4_13.pdf

To view the pharmacy regulations for oral prescriptions:  http://codes.ohio.gov/oac/4729-5-30

Q: May I prescribe Central Nervous System (CNS) stimulant medications?

A: According to the Ohio Board of Nursing Formulary (pg. 15), the CTP holder may prescribe Amphetamines and/or Methylphenidate HCL with a formal established diagnosis. Therefore, if the patient has a formal diagnosis documented, the CTP holder may initiate, modify, renew or discontinue as clinically indicated. If there is no formal established diagnosis, the CTP holder will need to indicate on the SCA if the medications in the class will be May Prescibe, Physician Initiation, Physician Consult or May Not Prescribe, then follow accordingly.

To view the current formulary:  http://www.nursing.ohio.gov/PDFS/AdvPractice/1-20-13_Formulary.pdf

 Q: I have a client with chronic pain and I am prescribing a schedule II medication. Can I write 3 scripts for the same dose indicating the date when one script could be filled without seeing the patient every month?

A: According to the U.S. Department of Justice; Drug Enforcement Agency; Office of Diversion Control; Code of Federal Regulations:

Section 1306.12 Refilling prescriptions; Issuance of multiple prescriptions.

(a) The refilling of a prescription for a controlled substance listed in Schedule II is prohibited.

(b)(1) An individual practitioner may issue multiple prescriptions authorizing the patient to receive a total of up to a 90-day supply of a Schedule II controlled substance provided the following conditions are met:

(i) Each separate prescription is issued for a legitimate medical purpose by an individual practitioner acting in the usual course of professional practice;

(ii) The individual practitioner provides written instructions on each prescription (other than the first prescription, if the prescribing practitioner intends for that prescription to be filled immediately) indicating the earliest date on which a pharmacy may fill each prescription;

(iii) The individual practitioner concludes that providing the patient with multiple prescriptions in this manner does not create an undue risk of diversion or abuse;

(iv) The issuance of multiple prescriptions as described in this section is permissible under the applicable state laws; and

(v) The individual practitioner complies fully with all other applicable requirements under the Act and these regulations as well as any additional requirements under state law.

(2) Nothing in this paragraph (b) shall be construed as mandating or encouraging individual practitioners to issue multiple prescriptions or to see their patients only once every 90 days when prescribing Schedule II controlled substances. Rather, individual practitioners must determine on their own, based on sound medical judgment, and in accordance with established medical standards, whether it is appropriate to issue multiple prescriptions and how often to see their patients when doing so.

To view the Code:  http://www.deadiversion.usdoj.gov/21cfr/cfr/1306/1306_12.htm

Q: I do not plan to prescribe schedule II analgesics in my practice. Do I still need to include this on my Standard Care Arrangement (SCA)?

A: Yes. You will need to include a statement that indicates you will not be prescribing schedule II analgesics. The Ohio Revised Code 4723.50 Administrative rules for prescribing drugs and therapeutic devices indicate that you: “Establish criteria for the components of the standard care arrangements described in section 4723.431 of the Revised Code that apply to the authority to prescribe, including the components that apply to the authority to prescribe schedule II controlled substances.”

Link to Ohio Revised Code 4723.50:  http://codes.ohio.gov/orc/4723.50

OAAPN sample SCA for purchase:  http://www.oaapn.org/index.php/store-oaapn/category/12-supplies

Q: It was brought to my attention that there are classes of medications for psychological disorders that APRNs specializing in psychiatric disorders may not prescribe without a prior authorization. Psychiatrists however are exempt from the prior authorization.

A: The authority of the insurance companies and Medicaid to deny APRNs access to these drugs when they are on the approved list in our BON prescriptive formulary is simply that there is no relationship between the two.  The formulary gives guidance on what is and is not approved for us to prescribe per the Ohio Board of Nursing, and the insurance companies and Medicaid have the right to delineate the parameters of their formularies.

Q: I have recently graduated and I am completing my CTP externship hours. Do I have my collaborating physician sign the prescriptions until I have completed the externship hours? Will I need my own prescription pad and if so, what numbers must I include on the prescription?

A: While completing the CTP externship, you may sign your own prescriptions. The Ohio Administrative Code:  4729-5-30 Manner of issuance of a prescription indicates the items which must be included on each prescription. Please refer to the following link:  http://codes.ohio.gov/oac/4729-5-30

Ohio Board of Nursing General Instructions and Application requirements for a CTP-E:  http://www.nursing.ohio.gov/PDFS/Forms/RXApp/CTP-E_1500_Hour_App_March_15_2013.pdf

2. QUALITY ASSURANCE

Q: Do you have any suggestions or recommendations for how many charts should be audited during the year for a CNP. I have not seen any specific recommendations just that there needs to be an audit.

A: The Ohio Board of Nursing does not specify how many charts should be reviewed. Specifically the rules state: "random" chart review and if you hold a CTP you must review a "representative sample".  See below. Depending on where you work the credentialing office may require a set amount of charts but the Board of Nursing does not.

4723-8-05 Quality assurance Standards

(D) Each practicing advanced practice nurse shall participate in a quality assurance process and shall immediately provide documentation satisfactory to the board of such participation upon request of the board. The quality assurance process shall include at a minimum:

(1) Periodic random chart review at least annually by a collaborating or supervising physician, podiatrist, dentist, or a designated member of a quality assurance committee, composed of physicians, of the institution, organization, or agency where the nurse has practiced during the period covered by the review. If the nurse holds prescriptive authority, the process shall include a procedure for periodic review, at least semi-annually, of prescriptions written and prescribing patterns for the holder of a certificate to prescribe;

4723-8-04 Standard Care Arrangement

C 12 (c) A procedure for the nurse and the collaborating physician, or a designated member of a quality assurance committee, composed of physicians, of the institution, organization, or agency where the nurse has practiced during the period covered by the review, to conduct a periodic review, at least semiannually, of:

(i) A representative sample of prescriptions written by the nurse;

(ii) A representative sample of schedule II prescriptions written by the nurse

To review the Ohio Administrative Codes:  http://codes.ohio.gov/oac/4723-8-05 and  http://codes.ohio.gov/oac/4723-8-04

3. HIRING AN ADVANCED PRACTICE NURSE

 Q: We are interested in hiring an APRN for our specialty practice. However we are having a difficult time finding compensation information in this specialty. Would you have any information or resources so we can make a fair offer to this new graduate?

A: There are many factors that are considered when hiring a NP and the salary/benefit package.  Here is a link that gives information on NP salaries from general practice to specialty practice:   http://nurse-practitioners-and-physician-assistants.advanceweb.com/Web-Extras/Online-Extras/The-Total-Package.aspx

Q: I would like some information that I can print about the role of the NP.   We have a new physician who is bringing his patients to the practice and many have never seen an NP.

A: The best brochure available on the role of the NP can be found on the AANP website at the following link:   http://www.aanp.org/publications/np-brochure

4. PERFORMING PROCEDURES

Q: I am a new graduate and I have accepted a position in which I will be required to perform special procedures including joint injections, suturing and interpreting radiological images. Am I able to perform these tasks?

A: The Ohio Board of Nursing has produced a Decision Making Guide for Determining Individual APN Scope of Practice. When performing any new procedure, please follow this guideline.  http://www.nursing.ohio.gov/PDFS/AdvPractice/APNModel(11-16-10).pdf

Also verify the tasks are included in your Standard Care Arrangement.

To review the Ohio Administrative code regarding Requirements for your Standard Care Arrangement:

 http://codes.ohio.gov/oac/4723-8-04

OAAPN sample SCA for purchase:  http://www.oaapn.org/index.php/store-oaapn/category/12-supplies

5. ORDERING HOME HEALTH/DURABLE MEDICAL EQUIPMENT/DIABETIC SHOES

Q: Can I order home health services for my patient?

A: According to federal statute, you may not order home health services or sign home health orders at this time. In order for patients to obtain home health care services, a face to face encounter with an eligible provider must occur within 90 days of the start of service. A nurse practitioner may conduct that encounter, but a physician must still document its occurrence.

Therefore the APN may complete the face to face encounter but the physician must still document that you completed the face to face and sign accordingly.

 http://www.aanp.org/legislation-regulation/federal-legislation/medicare/68-articles/326-medicare-update

Q: I am an APRN with a CTP. Can I order Diabetic Shoes?

A: According to CMS guidelines, 140 - Therapeutic Shoes for Individuals with Diabetes

(Rev. 1, 10-01-03) B3-2134 “Coverage of therapeutic shoes (depth or custom-molded) along with inserts for individuals with diabetes is available as of May 1, 1993. These diabetic shoes are covered if the requirements as specified in this section concerning certification and prescription are fulfilled. In addition, this benefit provides for a pair of diabetic shoes even if only one foot suffers from diabetic foot disease. Each shoe is equally equipped so that the affected limb, as well as the remaining limb, is protected. Claims for therapeutic shoes for diabetics are processed by the Durable Medical Equipment Regional Carriers (DMERCs).”…“The need for diabetic shoes must be certified by a physician who is a doctor of medicine or a doctor of osteopathy and who is responsible for diagnosing and treating the patient’s diabetic systemic condition through a comprehensive plan of care.”

To review the CMS guidelines:  http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf page 133

 

6. DEATH CERTIFICATES

Q: Can you share the rule on signing death certificates? I was told that this law recently changed.

A: Ohio Revised Code 4723.36, effective 3/22/13 allows the Declaration of death by Certified Nurse Practitioner or Clinical Nurse Specialist in certain circumstances.  See the below link for details. However, the physician must still sign the death certificate.

To review Ohio Revised Code 4723.36 Declaration of death by certified nurse practitioner or clinical nurse specialist:  http://codes.ohio.gov/orc/4723.36

To review Ohio Revised Code 3705.16 Statement of facts in certificates – death certificate:  http://codes.ohio.gov/orc/3705.16

7. DELEGATION

Q: I am an APRN. Can I delegate to the Medical Assistant in my office?

A: According to Ohio Administrative Code 4723-13-05, a registered nurse may delegate a nursing task under certain conditions. Also included in this rule is the delegation of over-the-counter topical medications to be applied to intact skin for the purpose of improving a skin condition or providing a barrier; and over-the-counter eye drop, ear drop, and suppository medications, foot soak treatments, and enemas. OAAPN identifies there are barriers to practice due to the inability to delegate medication administration to unlicensed personnel. Therefore we are working diligently on this matter.

To review the Ohio Administrative Code regarding delegation:  http://codes.ohio.gov/oac/4723-13-05

8. CONCUSSION

Q: I have an athlete in my practice who sustained a concussion during a recent athletic event. May I now grant clearance?

A: According to Ohio Revised Code 3313.539 (effective date 4/26/13), a school district board of education or governing authority of a chartered or nonchartered nonpublic school may authorize a licensed health care provider who is not a physician to make an assessment or grant a clearance…in collaboration with a physician. Make sure this is included on your Standard Care Arrangement.

To review the Ohio Revised Code 3313.539:  http://codes.ohio.gov/orc/3313.539

OAAPN sample SCA for purchase:  http://www.oaapn.org/index.php/store-oaapn/category/12-supplies

9. REIMBURSEMENT

Q: Do you know if OH Medicaid will reimburse hospitals for inpatient services provided by an APRN who is employed by the hospital?

A: Ohio Medicaid reimburses APRNs for hospital services as long as the APRN is not included on the hospital cost report.  The APRN could be hired as a hospitalist and the hospital would bill for all services that are billed as physician services (same billing rules as applied to an employed physician).  The hospital cannot bill for services as physician services if the APRN remains on the Medicare hospital cost report.

10. COLLABORATION

Q: Can you tell me if physicians have a limit on the number of APN's they collaborate with?

A: The Ohio Revised Code 4723.431 states:  A clinical nurse specialist, certified nurse-midwife, or certified nurse practitioner may enter into a standard care arrangement with one or more collaborating physicians or podiatrists.  Each physician or podiatrist must be actively engaged in direct clinical practice in this state and practicing in a specialty that is the same as or similar to the nurse's nursing specialty. If a collaborating physician or podiatrist enters into standard care arrangements with more than three nurses who hold certificates to prescribe issued under section 4723.48 of the Revised Code, the physician or podiatrist shall not collaborate at the same time with more than three of the nurses in the prescribing component of their practices.

To review the Ohio Revised Code regarding Standard Care Arrangements:  http://codes.ohio.gov/orc/4723.431