Section 107.122. Independent nurse practitioner services.

 

(1)   Covered services. Services provided by a nurse practitioner, including a clinical nurse specialist, which are covered by the MA program are those medical services delegated by a licensed physician by a written protocol developed with the nurse practitioner pursuant to the requirements set forth in s. N 6.03 (2) and guidelines set forth by the medical examining board and the board of nursing. General nursing procedures are covered services when performed by a certified nurse practitioner or clinical nurse specialist in accordance with the requirements of s. N 6.03 (1) . These services may include those medically necessary diagnostic, preventive, therapeutic, rehabilitative or palliative services provided in a medical setting, the recipient's home or elsewhere. Specific reimbursable delegated medical acts and nursing services are the following:

(a) Under assessment and nursing diagnosis:

1. Obtaining a recipient's complete health history and recording the findings in a systematic, organized manner;

2. Evaluating and analyzing a health history critically;

3. Performing a complete physical assessment using techniques of observation, inspection, auscultation, palpation and percussion, ordering appropriate laboratory and diagnostic tests and recording findings in a systematic manner;

4. Performing and recording a developmental or functional status evaluation and mental status examination using standardized procedures; and

5. Identifying and describing behavior associated with developmental processes, aging, life style and family relationships;

(b) Under analysis and decision-making:

1. Discriminating between normal and abnormal findings associated with growth and development, aging and pathological processes;

2. Discriminating between normal and abnormal patterns of behavior associated with developmental processes, aging, life style, and family relationships as influenced by illness;

3. Exercising clinical judgment in differentiating between situations which the nurse practitioner can manage and those which require consultations or referral; and

4. Interpreting screening and selected diagnostic tests;

(c) Under management, planning, implementation and treatment:

1. Providing preventive health care and health promotion for adults and children;

2. Managing common self-limiting or episodic health problems in recipients according to protocol and other guidelines;

3. Managing stabilized illness problems in coloration with physicians and other health care providers according to protocol;

4. Prescribing, regulating and adjusting medications as defined by protocol;

5. Recommending symptomatic treatments and non-prescription medicines;

6. Counseling recipients and their families about the process of growth and development, aging, life crises, common illnesses, risk factors and accidents;

7. Helping recipients and their families assume greater responsibility for their own health maintenance and illness care by providing instruction, counseling and guidance;

8. Arranging referrals for recipients with health problems who need further evaluation or additional services; and

9. Modifying the therapeutic regimen so that it is appropriate to the developmental and functional statuses of the recipient and the recipient's family;

(d) Under evaluation:

1. Predicting expected outcomes of therapeutic regimens;

2. Collecting systematic data for evaluating the response of a recipient and the recipient's family to a therapeutic regimen;

3. Modifying the plan of care according to the response of the recipient;

4. Collecting systematic data for self-evaluation and peer review; and

5. Utilizing an epidemiological approach in examining the health care needs of recipients in the nurse practitioner's caseload;

(e) Physician services described under s. DHS 107.06 that are under protocol;

(f) Services under s. DHS 107.08 performed for an inpatient in a hospital;

(g) Outpatient hospital services, as described in s. DHS 107.08 (1) (b) ;

(h) Family planning services, as described in s. DHS 107.21 ;

(i) Early and periodic screening, diagnosis and treatment (EPSDT) services, as described in s. DHS 107.22 ;

(j) Prescriptions for drugs and recipient transportation; and

(k) Disposable medical supplies, as described in s. DHS 107.24 .

(2)   Prior authorization.

(a) Services under sub. (1) (e) to (k) are subject to applicable prior authorization requirements for those services.

(b) Requests for prior authorization shall be accompanied by the written protocol.

(3)   Other limitations.

(a) No services under this section may be reimbursed without a written protocol developed and signed by the nurse practitioner and the delegating physician, except for general nursing procedures described under s. N 6.03 (1) . The physician shall review a protocol according to the requirements of s. 448.03 (2) (e) , Stats., and guidelines established by the medical examining board and the board of nursing, but no less than once each calendar year. A written protocol shall be organized as follows:

1. Subjective data;

2. Objective data;

3. Assessment;

4. Plan of care; and

5. Evaluation.

(b) Prescriptions for drugs are limited to those drugs allowed under protocol for prescription by a nurse practitioner, except that controlled substances may not be prescribed by a nurse practitioner.

(4)   Non-covered services. Non-covered services are:

(a) Mental health and alcohol and other drug abuse services;

(b) Services provided to nursing home residents or hospital inpatients which are included in the daily rates for a nursing home or hospital;

(c) Rural health clinic services;

(d) Dispensing durable medical equipment; and

(e) Medical acts for which the nurse practitioner or clinical nurse specialist does not have written protocols as specified in this section. In this paragraph, "medical acts" means acts reserved by professional training and licensure to physicians, dentists and podiatrists.

Emerg. cr. eff. 7-1-90; cr. Register, January, 1991, No. 421 , eff. 2-1-91; correction in (1) (e) made under s. 13.93 (2m) (b) 7., Stats., Register, April, 1999, No. 520 .