Advanced Practice Advocacy

Call to Action from AANP/ NONPF

Our Advocacy Chair received the following message from the AANP on September 6, 2018:

 AANP has been actively involved in the issue related to documentation for NP preceptors for reimbursable billing. In March CMS changed the rules for Physician preceptors but not for NP or PA preceptors.  AANP met with CMS (along with NONPF, AACN, PAEA, AAPA, and STFM) last week.   Correspondence was drafted that the NONPF sent out along with the other groups and are submitting a version of that language in our comments, as well as to CMS directly pursuant to our meeting. We would encourage anyone who would like to comment on the issue to use similar language.

CALL TO ACTION: Submit Comment on NP Student Documentation Regulations- Deadline midnight Monday, September 10th.

You may have heard the recent change in federal policies on the documentation of evaluation and management services. Nurse practitioner (NP) preceptors and NP students were not include in this policy.  The reduction of burden was only for teaching physician and medical students. The new policy threatens availability of clinical placement for NP students.  We need your help!

NONPF members have an opportunity to help correct this policy by submitting comments on the proposed rule for the 2019 Medicare Part B fee schedule (CMS- 1693-P).  Comments must be submitted to the agency by midnight Monday, September 10th. Read more for instructions to submit comments and NONPF’s recommended comments.


Prior to March 5, 2018 for billable evaluation and management (E/M) services, all clinical preceptors (teachers) had to re-document the clinical notes of medical students, nurse practitioner (NP) students and physician assistant (PA) students.  The Centers for Medicare & Medicaid Services (CMS) released Transmittal 3971 (subsequently Transmittal 4068), revising the Medicare Claims Processing Manual, effective March 5, 2018, to allow teaching physicians to verify in the medical record any student documentation of the components of E/M services, rather than re-document the work.  Unfortunately, the agency didn’t extend the same burden reduction to NP and PA students and their NP and PA preceptors, even though they fill the same role as teaching physicians.

The new policy has the unintended consequence of increasing the disparity between services provided by medical students and NP and PA students, as well as the documentation standards for teaching physicians and precepting NPs and precepting PAs.  These disparities have already led some facilities to be less willing to train NP and PA students and raised an additional barrier to recruitment of NP and PA preceptors.

Regulatory Comments

On July 27, 2018, CMS released proposed regulations for the 2019 Medicare Part B fee schedule, commonly referred to as the “physician fee schedule.” That rule proposes unrelated changes to teaching physician policies – but it offers the opportunities for PNPs to urge the agency to address the policies that disadvantage NP students and preceptors.  Since the problematic policies proposed in March have already gone into effect and started to impact NP students and preceptors, CMS should act immediately to adjust its policies to provide equitable treatment of teaching physicians and NP and PA preceptors.

We are calling on NONPF members to submit comments (instructions below) recommending the following changes to current policies:

1.     Apply the Teaching Physician Documentation Requirements to All E/M Visits

 In the proposed fee schedule rule, CMS is already suggesting policies to reduce documentation redundancy for all E/M visits.  By applying the March 2018 teaching physician requirements from Transmittal 4068 to all E/M visits, the agency can reduce duplicative policies for all E/M visits, including E/M visits documented by NP and PA students and verified by NP and PA preceptors.  CMS can accomplish this through its current rulemaking and have it go into effect immediately.

2.     Provide equitable policies for Teaching Physicians and NP and PA Preceptors, and for Medical Students and NP and PA Students

CMS can also acknowledge the role of NP and PA preceptors and students by extending regulations and guidance for teaching physicians and medical students to include NP and PA preceptors and students.  To accomplish this, the agency should:

·       Include NP preceptors and PA preceptors in the definition of “teaching physician.”  The Secretary has statutory authority to define        “teaching physician” and could include NP and PA preceptors, preferably using the term “teaching clinician.”  If CMS believes such a change would require additional rulemaking, the Secretary could use his existing waiver authority or issue a nonenforcement instruction to Medicare carriers to immediately extend the teaching physician policies to NP and PA preceptors.

·       Include NP and PA Students in the interpretation of “Student.”  CMS has the authority to interpret the word “student” in Transmittal 4068 to include NP and PA students. The term “student” is not defined in regulation, and the existing definition of “student” in the Medicare Claims Processing Manual already includes NP and PA students.  Harmonizing this interpretation could be accomplished through guidance, would not require rulemaking.


How to Submit Comments on Documentation and Precepting Of NP Student Services


1.     Go to the website (

2.     Type your comments in the text box provided – or upload comments written in a separate document or file.

        a.     Use the background information and policy recommendations provided above in drafting your comments.

        b.     It is critically important for you to provide examples of how these policies could have a damaging impact on your students and your institution.                      Anecdotal evidence of the harm these policies will do is very valuable.

3.     Complete the form with your name and contact information.

4.     When complete, click on the “Continue” arrow.  On the next page, review your comment and information – then click the box that you understand                 you are submitting publicly viewable comments and click “Submit Comments.”

5.     You will have an opportunity to have a receipt for your comments e-mailed to you, if you choose, to an address that you provide.

Frequently Asked Questions

Who can I talk with at Saint Louis Nurses in Advanced Practice about how government affects advanced practice nursing?

Two board members are elected by the membership to the position of Advocacy Co-Chair. They can be contacted simultaneously by emailing

How can I help to shape legislation that affects me?

Writing (fax, email, regular mail) or calling your elected official with a clear and succinct message overviewing your support or opposition for proposed legislation can make a difference in how laws that affect you take shape.

When contacting your elected official, be sure to reference the name of the legislation and the section that your oppose or endorse.

It’s been a long time since I studied government structure and function. Where can I go for a succinct overview of state and federal government for nurses?

The Missouri Nurses Association (MONA) gives a helpful overview in their Advocacy Handbook.

Who represents me at the state and federal levels in Missouri?

Missouri Legislator Lookup

Who represents me at the state and federal levels in Illinois?

Find Representatives Full version / Find Representatives Mobile / Lite Version

How can I view pending legislation that may affect my nursing practice?

The Missouri Nurses Association (MONA) tracks pending legislation salient to nurses on their website under the “Legislative Affairs” menu in blue on the left-hand side of their webpage.  link relates how advocacy on Capitol Hill in DC is being handled through social media…check it out and “like” or “friend”  your State Representative or State Senator on Facebook.


Governor Parson signed Senate Bill 718 on Friday, July 6.  SB 718 contains legislation regarding the ratio for APRN’s to physicians.
COLLABORATIVE PRACTICE AND SUPERVISORY AGREEMENTS: Current law authorizes physicians to enter into a collaborative practice agreement with 3 advanced practice registered nurses (APRN) and 3 assistant physicians, and a supervising agreement with 3 licensed physician assistants. This act authorizes physicians to enter into a collaborative practice agreement or a supervising agreement with 6 APRNs, assistant physicians, licensed physician assistants, or any combination thereof.

Also, the bill allows the following provisions for APRN’s:
Advanced practice registered nurses and physician assistants may prescribe buprenorphine for up to a 30-day supply without refill in certain circumstances.
The act adds psychiatric physician assistants, psychiatric advanced practice registered nurses, and psychiatric assistant physicians to the definition of mental health professionals for the purposes of provisions of law relating to alcohol and drug abuse and comprehensive psychiatric services and adds a definition for each term.

The act allows unused controlled substances to be accepted from the public through collection receptacles, drug disposal boxes, and other means provided through drug take back programs by a drug enforcement agency authorized collector in accordance with federal regulations, regardless of whether or not the authorized collector originally dispensed the drug. The act requires the Department of Health and Senior Services to develop an education and awareness program about drug disposal by August 28, 2019.
For a copy of the full bill text, click here:
Thank you to everyone who helped get these issues across the finish line.  The legislation will go into effect on August 28

Pending Bills in Missouri  **Senate passed legislation for Missouri Prescription Drug Monitoring Program- Vote moves to House!


Pending Bills in Illinois