CMS Revises Manual Instructions for the NOA and Allowed Practitioners

From NAHC

The Centers for Medicare & Medicaid Services (CMS) has issued Change Request (CR) 12615 that incorporates policies for the implementation of the  Notice of Admission (NOA) and the subsequent elimination of the Request for Anticipated Payment (RAP). The NOA became effective January 1, 2022.

The CR also provides corrections and clarifications regarding who may sign the certification and plan of care  for home health beneficiaries at section 30.2.1 of the Medicare Benefit Policy Manual.

CMS has not altered any of the policies around the contents, criteria for submission, and untimely submission policy of the NOA.

The revisions in the CR to section  30.2.1 – Definition of an Allowed Practitioner, incorporates the requirements for physician assistant, nurse practitioner, and certified nurse specialist at §410.74, §410.75 and §410.76 respectively. These same requirements are incorporated into the home health Conditions of Participation  at §484.2- Definitions.  CMS has not changed their policy around defining these non-physician practitioners but providing consistency in their policies on the requirements for PAs, NPs and CNSs.

CMS permits these NPPs to practice with in their scope of practice in accord with state laws. Several states do not require a collaborative agreement or other documentation of collaboration with a physician, while other states have specific collaborative arrangement requirements for which NPPs must   comply with when caring for home health patients.  However, where the state is silent on collaboration for an NP and CNS,  CMS, in accord with§ 410.75(c)(3)(ii) and §410 .76(c)(3)(ii),  requires  that the practitioner have  documentation  on her/his scope of practice and some information on how she/he deals with patients whose needs are outside the scope of practice for an NP or CNS as evidence of collaboration, but CMS does not require a collaborative agreement with a physician. 

• 410.75 (c)(3)(ii). In the absence of State law governing collaboration, collaboration is a process in which a nurse practitioner has a relationship with one or more physicians to deliver health care services. Such collaboration is to be evidenced by nurse practitioners documenting the nurse practitioners’ scope of practice and indicating the relationships that they have with physicians to deal with issues outside their scope of practice. Nurse practitioners must document this collaborative process with physicians.

• 410.76(c)(3)(ii). In the absence of State law governing collaboration, collaboration is a process in which a clinical nurse specialist has a relationship with one or more physicians to deliver health care services. Such collaboration is to be evidenced by clinical nurse specialists documenting the clinical nurse specialists’ scope of practice and indicating the relationships that they have with physicians to deal with issues outside their scope of practice. Clinical nurse specialists must document this collaborative process with physicians.

The National Association for Home Care & Hospice (NAHC) is somewhat puzzled why CMS chose the phrase  “….however, a CNS and NP must work in collaboration with a physician in accordance with §§ 410.76(c) and 410.75(c) even if state laws governing collaboration do not exist.”  to describe the requirements for collaboration where the state is silent.

NAHC will be requesting information from CMS on compliance expectations for the revised manual changes at section 30.2.1 , particularly what the Medicare contractors will be looking for during medical review.