Author: Brooke Trainum

Brooke Trainum is the Director, Policy and Regulatory Advocacy in ANA’s Department of Policy and Government Affairs where she works on emerging issues related to health systems, telehealth, and regulatory policy. In this capacity she collaborates with external and internal stakeholders to contribute to policy statements, regulatory comments, and legislative testimony. Passionate about improving health outcomes through policy and best practices, Brooke has worked in both the United States and Internationally in a variety of clinical, public health, and policy settings; collaboratively working to transform individual and community health. Brooke holds a juris doctor, with a certificate of International law, from the University of Denver, Sturm College of Law and a bachelors of science, in human nutrition, foods, and exercise, from Virginia Tech.

HIMSS 2022: When Nurses Reimagine Health Care

  

ANA staff attended the 2022 Health Information and Management Systems Society (HIMSS) conference last week where reimagining health and the health care delivery system were top of mind. The week started by reimagining health with a NursePitchTM Innovation event. ANA’s Innovation Department collaborates with HIMSS by setting the stage for nurses to share their creative business ideas and programs to a team of judges, who are health innovation, business, and industry leaders. ANA knows that nurses have important ideas and approaches that can positively change the health delivery system and we encourage them to learn more and be ready to present at an event in the future!

It would be an understatement to say that the nursing workforce was top of mind in discussions around reimagining health. Attendees at HIMSS22 represent a microcosm of the health sector and have been living during the seismic shift that the delivery system has done over the past two years. The COVID-19 pandemic has triggered the need to adapt to new treatments, delivery options, and other environmental factors. Another key focus for the health care industry is developing new ways to support providers facing the challenges of today and the hope of the health system of the future. Digital tools can help with flexible scheduling, reduce duplications in workflow, and assist in charting. However, ANA continues the drumbeat about the importance of health systems valuing nurses through reimbursement, safe work environments, and ensuring each and every nurse achieve health equity in order to meaningfully solve the staffing crisis.

Over the course of the pandemic, we have also seen reports of the increase in digital technologies to deliver health services. The increased use happened seemingly overnight and is unlikely to return to pre-February 2020 levels ever again. At the same time, we must reflect and address the existing digital divide. Investments in our workforce must reflect the patient population in every community is vital, but we also need to make sure that the digital tools that are being used to assist in clinical decision making are free from unintentional biases. Just as important for patients, we must also ensure that nurses have access to the same opportunities to reach their own health equity—the nation cannot have a workforce that is shut off from the same system they provide care in.

Attending the HIMSS 2022 conference provided a great opportunity to learn, connect, and share ideas with others working to better the health care delivery system. The one thing missing was nurses on the big stage. ANA knows that nurses have stories, research, and ideas to share and together, we must be bold, step forward, and ensure our voices are heard in front of industry leaders as we all work to shape the health delivery system of the future.

FY 2022 budget proposal sets the stage for Biden administration

  

The Biden administration released its proposed FY 2022 budget, which helps bring some clarity to the continued priorities of the administration. The budget reflects the administrations promise to rebuild a strong public health and community-based care system that can respond to the health challenges faced in diverse areas across the United States. Many priorities of the administration align with ANA’s advocacy focus to support nurses in areas such as workforce, behavioral health, maternal health, rural health, preparedness and safety including personal protective equipment (PPE), and research.

Below are a few highlights from the proposed budget that align with the work of ANA:

  • $15.4 billion for the Centers for Disease Control and Prevention, which reflects the largest budget authority increase in nearly two decades. The funding would go to support core public health capacity improvements, modernize data collection, training for public health experts, and prepare for, and respond to emerging global threats.
  • $12.6 billion for the Health Resources and Service Administration, which is $497 million above FY 2021 enacted.
  • $52 billion for the National Institutes of Health (NIH), an increase of $9 billion above FY 2021 enacted. $6.5 billion of the $9 billion increase is to support the establishment of the Advanced Research Projects Agency for Health, that is intended to speed transformational innovation in health research for diseases like cancer, diabetes, and Alzheimer’s. The remaining $2.5 billion will continue the research and translation into clinical practice for some of the most urgent challenges including the opioid crisis, climate change, and gun violence. ANA continues to monitor communications and opportunities to engage with the National Institute of Nursing Research under NIH.
  • An increase of $3.7 billion above FY 2021 enacted, for a total of $9.7 billion for the Substance Abuse and Mental Health Services Administration with a charge to respond to the opioid and substance use epidemic by expanding programs and targeting prevention and treatment; and increasing access to mental health services to protect the health of children and communities.
  • $14.2 billion for the Department of Labor (DOL), including $665 million for the Occupational Safety and Health Administration (OSHA), $73 million above FY 2021 enacted, for increased enforcement and whistleblower protection programs. The DOL budget requests $285 million for apprenticeship programs, specifically $100 million increase for the Registered Apprentice Program. There is no additional information on the DOL industry-recognized apprenticeship programs (IRAPs), which have supported nurse training initiatives.

The Biden administration has been vocal about priorities that will transform the health care system. However, the administration’s budget is slightly more than a wish list. Ultimately it is up to Congress to fund the agencies. ANA urges the Administration and Congress to focus on rebuilding and transforming the health care system to improve on the challenges brought forth during the pandemic. Nurses have been the agents of transformative change in facilities, systems, and communities to support improved patient outcomes and advancing equity. Building on these successes, ANA will work with the agencies and administration to build on the budget priorities to continue to put nurses at the forefront of change.  

ANA is also working on the Hill for legislation that will address infrastructure and access for telehealth services, PPE for the current and future public health emergencies, and workplace safety programs for nurses. ANA’s advocacy includes a multi-pronged approach to deliver what nurses need in all settings. It is clear through the first budget of this administration that health care is a top priority to improve as we transition to a post-pandemic environment.

Evaluation and Management Code Changes Coming in 2021 for 99202-99215

  

While it is only the second month of 2020, it is never too early to look to 2021, when the revised Evaluation and Management (E/M) office codes go into effect per the Centers for Medicare and Medicaid Services (CMS) CY 2020 Physician Fee Schedule (PFS) Final Rule. CMS first proposed the updated Medicare E/M codes July 2018 in the CY 2019 PFS proposed rule to address the common perception that the E/M codes were outdated and to achieve administrative simplification. What is changing?

  • Deletion of code 99201
  • Revision of codes 99202-99215P
  • Components for code selection
  • E/M level of service for office or other outpatient services can be based on:
    • Medical Decision Making (MDM); or
    • Time: total time spent with the patient on the date of the encounter, including non-face-to-face services
  • Creation of a shorter 15-minute prolonged service code

Over the next few months ANA will take a deeper dive into these changes and will continue to share further guidance from CMS. These code changes are intended for increased simplicity and flexibility.  They eliminate the need for the clinician to redocument information, therefore reducing burden and “note bloat”. ANA encourages clinicians impacted to take the next eleven months to better understand how to use the updated codes.

With code 99201 deleted; the Office or other Outpatient Services: new patient code starts with 99202. The updated code states: Office or other outpatient visit for the evaluation and management of a new patient, which requires medically appropriate history and/or examination and straightforward medical decision making. The components of history and examination are removed from this updated code.

This continues for 99203, 99204, and 99205 but with the increase in MDM to low MDM, moderate MDM, and high MDM respectively. Codes 99211 through 99215 are for established patients following a similar pattern, except that 99211 will still be available in 2021 with an update of the time to spend performing or supervising the services.

The updated modifications to the criteria for MDM remove ambiguous terms and defines previously ambiguous concepts (such as acute or chronic illness with systemic systems). To qualify for a level of MDM, two of three elements for that level of decision making must be met or exceeded. Starting January 1, 2021, the new MDM table looks like:

Number and Complexity of Problems Addressed at the Encounter
Straightforward: self-limited
Low: Stable, uncomplicated, single problem
Moderate: multiple problems or significantly ill
High: very ill
Amount and/or Complexity of Data to be Reviewed and Analyzed Data is divided into three categories: (1) tests, documents, orders, or independent historian(s) – each unique test, order, or document is counted to meet a threshold number; (2) independent interpretation of tests not reported separately; (3) discussion of management or test interpretation with external physician/other Qualified Health Professional/appropriate source (not reported separately)
Risk of Complications and/or Morbidity or Mortality of Patient Management
Includes risks associated with social determinants of health
Straightforward: minimal risk from treatment – including no treatment – or testing. (effectively no risk)
Low: low risk/very low risk of anything bad, minimal consent/discussion Moderate: would typically review with patient/surrogate, obtain consent and monitor, or there are complex social factors in management (ex: prescription drug management, decision regarding minor surgery with identified patient or procedure risk factors, diagnosis or treatment significantly limited by social determinants of health)
High: need to discuss some pretty bad things that could happen for which physician or other qualified health care professional will watch and monitor (ex: drug therapy requiring intensive monitoring for toxicity, decision regarding emergency major surgery, decision regarding hospitalization)

ANA will continue to provide updates and content as clarifications become available. Currently, The American Medical Association has a module to continue in your education on the updated E/M Office Codes and remember that these codes do not go into effect until January 2021.