CNAP Interim Update #4 - Online Rx Delegation

CNAP Interim Update

Lynda Woolbert, Executive Director

Coalition for Nurses in Advanced Practice

August 8, 2010

In this CNAP Update...

Physicians register Rx delegation with the TMB online.

TMB proposes rule to clarify physicians do not register delegation to CRNAs.

CNMs join NPs and CNSs as APRNs who may order glucose testing supplies for Medicaid patients.

Rx style="cursor: hand; border-bottom: #366388 2px dotted;">Delegation Now Online

As of August 1, 2010, the Texas Medical Board (TMB) requires physicians to register their prescriptive (Rx) authority delegations online.  This is good news for APRNs.  As of the first week in August, the TMB was still working through a 3 to 4 week backlog of paper forms to get delegations posted. In contrast, online registration will allow APRNs to appear on the TMB website as having delegated prescriptive authority within one day of completing the online registration.

The paper form has been replaced by the Online Supervision and Prescriptive Delegation Registration System. While most celebrate the change, APRNs and physicians need to understand some basics about the system and the steps to completing the registration.

Who Needs to Register Online? 

Only delegations not already reported to the TMB via a paper form between November 2009 and August 1, 2010, must be reported online. Eventually, all delegating physicians and APRNs with delegated Rx authority will have to establish accounts in the Online Prescriptive Delegation Registration System. This system will be used to:

·         update existing information on delegations and locations;

·         terminate delegations ; and

·         register new delegations.

Any APRNs and physicians who recently submitted a paper form to the TMB, but the TMB has not yet posted the APRN’s name with the delegating physician records in TMB’s licensure verification system, has the option to also register the delegation online.

Who Must Register But May Not Qualify for Online Registration?

There are some APRNs that will have to call the TMB Pre-Licensure, Registration and Consumer Services (PRC) Department at (512) 305-7030.  This includes APRNs who received their prescriptive authority numbers after the data on APRNs with current prescriptive authority was downloaded into the system.  Those APRNs will simply need to call PRC and they will be able to set up an account in the system.

The webpage lists certain physicians and APRNs that have special or restricted licenses. The TMB will have to determine if these APRNs or physicians qualify to be registered in the system. Physicians and APRNs with any restrictions on their licenses must call the PRC.  In most cases, the physician or APRN will have to apply using the paper form and TMB staff will determine eligibility on a case by case basis. Some APRNs working on a restricted license will still be able to have delegated prescriptive authority as long as their Board Order does not restrict their prescriptive privileges. The paper Rx Delegation Form is no longer available online and is only available through the PRC.

Who Should NOT Register Delegated Rx Authority? 

Delegated prescriptive authority applies to those APRNs who sign prescriptions filled at outpatient pharmacies and order medications for administration in long-term care facilities and out-patient ambulatory care settings. Therefore, physicians who only delegate the ordering of drugs and devices necessary for the CRNA to administer anesthesia do not register the names of those CRNAs. (See article below) In addition, physicians who sign the prescriptive authority delegation protocol only as alternate delegating physicians are not required to register.

The Online Rx Delegation Process

1. Establish an Account. Both the delegating physician and the APRN to whom the physician is delegating Rx authority must establish accounts. Most APRNs who received a prescriptive authority number before the end of October 2009, will find this easy to do. Just enter your RN license number and the system will recognize you and ask you to establish your username and password.

As stated above, APRNs who received their prescriptive authority number after October 2009 are probably not in the system. If you enter your RN license number and the system does not match one of the RN license numbers already in the system, you will see a prompt to call the Pre-Licensure, Registration and Consumer Services (PRC) at 512-305-7030. When you call, you will need to have your RN license and prescriptive authority numbers. Tell the TMB staff person that you have a new prescriptive authority number and they will enter your data manually. If you just received your APRN authorization and prescriptive authority number, check the BON’s online APRN verification system before calling the TMB.  If the BON has not yet posted your authorization and prescriptive authority verification, TMB will not enter your information in their system.

2.  APRN Enters Requested Data and Rx Sites. To complete this section, the APRN will need to have certain information to complete all required data fields.

• Delegating physician’s Texas license number
• Addresses of all locations where the APRN will prescribe
• Type of practice site under which each location qualifies for the physician to delegate Rx authority, i.e. primary, alternate, medically underserved population, hospital facility-based or long-term care facility-based (For more information on determining the type of practice site, see the CNAP prescriptive authority webpage.)
• Types of drugs delegated, i.e., “dangerous drugs” and/or “controlled substances” (At a minimum, the physician is delegating prescriptive authority for dangerous drugs, defined as drugs that can only be dispensed with a prescription signed by a licensed practitioner. Mark controlled substances if the physician is also delegating any authority to prescribe drugs that are on Schedules III – V. Remember, in order to obtain or renew a DPS permit under this physician’s delegation, controlled substances must be marked in addition to dangerous drugs.)
• Number of hours a week the APRN will be working at this location under the physician’s delegated prescriptive authority (The prompt for this field asks the number of hours per week the APRN works for the physician at each site. Do not take this wording too literally. The physician does not have to employ the APRN in order to delegate Rx authority. The TMB is only asking for an accurate estimate of the hours the physician is responsible for the APRN’s prescribing practices at each location where that physician delegates prescriptive authority. This information is used to estimate the number of FTEs to whom the physician is delegating prescriptive authority.)
• APRN attests the information is correct

3. Physician Attests to Delegation. The TMB requires the physician complete the attestation last (after the APRN). The physician reviews data entered by the APRN, enters any missing information or makes corrections, as necessary. (Thank goodness for physician supervision! J ) Then the physician attests that the information is correct. This is the last step in the registration process. After the physician completes his/her attestation, the APRN’s name should appear on the TMB website the following day.

FTEs & Warnings

The TMB designates 50 hours as 1 full time equivalent (FTE). The online registration system is set to warn physicians if they are delegating Rx authority to more than 4 FTEs (Rx delegations total more than 200 hours a week). The warning does not prevent physicians from registering additional APRNs or PAs, because the system is not sophisticated enough to know if the physician is delegating at sites in which there is no limit on the number of FTEs (medically underserved and hospital facility-based) or if the physician has a waiver from the TMB that allows him/her to delegate to more than four FTEs.

The system is also set to warn physicians if they are delegating at more than 3 medically underserved sites. This warning, like the one related to FTEs, does not stop the physician from registering additional delegations. It just alerts the physician that he/she might be violating a rule, and refers the physician to the rules.

Keeping Registrations Up to Date

TMB rules require physicians to notify the TMB if they terminate a prescriptive authority delegation. The TMB allows either the APRN or physician to terminate the delegation through the online system.  Locations where APRNs are prescribing and the site designation at that location should also be kept current.

CRNAs Do Not Register

CRNAs do not need delegated prescriptive authority to provide anesthesia, but may for certain related services. The exception occurs when CRNAs need to sign prescriptions that will be filled at an outpatient pharmacy or are writing an order in a long-term care facility. Usually, this situation only exists when CRNAs are doing pain management in outpatient settings or writing pain medications for patients being discharged.

While this has always been true, some hospital attorneys and physicians began asking the TMB if physicians who were delegating the ordering of drugs and devices to provide anesthesia or related services needed to register that delegation. The registration requirement only applies to delegated prescriptive authority and, as stated above, most CRNAs do not have or need delegated prescriptive authority.

To clarify the issue, the TMB proposed an amendment to its documentation of supervision rule [22 TAC §193.6(f)(3)] in the July 16, 2010, issue of the Texas Register. The proposed amendment states, “Certified registered nurse anesthetists who sign or carry out medication orders as defined in Texas Occupations Code §551.003(24) are not required to register with the board.”

The citation from the Occupations Code refers to the Pharmacy Practice Act that defines a “medication order” as “an order from a practitioner or a practitioner’s designated agent for administration of a drug or device.”  The Pharmacy Practice Act contains a distinctly different definition for a “prescription drug order.”  Prescription drug order is defined as “an order from a practitioner or a practitioner’s designated agent to a pharmacist for a drug or device to be dispensed…”.

The Texas Association of Nurse Anesthetists (TANA) submitted a comment to the Texas Medical Board support ing the addition to the rule, but recommending that the language be changed to state:

A physician who delegates to a certified registered nurse anesthetist the ordering of drugs and devices necessary for the certified registered nurse anesthetist to administer an anesthetic or an anesthesia-related service is not required to register the name and license number of the certified registered nurse anesthetist with the board.

The revised language TANA is recommending clarifies that it is the physician who is required to register, not the CRNA. It is inappropriate for Texas Medical Board Rules to ever direct APRNs to do, or not to do anything. APRNs are regulated totally by the Texas Board of Nursing. Likewise, the Texas Medical Board has exclusive authority to regulate physicians who delegate prescriptive authority.  Initial response of the TMB staff to the proposed change was positive, but it requires a vote of the TMB at their next meeting on August 26 – 27, 2010.

CNMs May Order Glucose Testing Equipment for Medicaid

In November 2009, the Texas Medicaid & Healthcare Partnership announced that the Texas Medicaid Program would no longer require a Title XIX Form to order glucose testing equipment. Instead, DME suppliers could accept detailed written orders or verbal orders followed by detailed written orders.  Since Title XIX forms can only be signed by a physician, this change also expanded the providers eligible to order glucose testing supplies. As originally announced, NPs, CNSs and PAs were added to the list of authorized prescribing providers. Then in a July 9, 2010, update,  TMHP announced that CNMs were incorrectly overlooked and are included on the list of providers who may prescribe glucose testing supplies.

There are two sources of information on the requirements for verbal and written orders for these supplies. The easiest to find is the Texas Medicaid Bulletin No. 227 (January/February 2010), p. 29. The Texas Medicaid Provider Procedure Manual, Volume 2, Section 1.2.10.1 (pg. 29) – 1.2.10.3 (pg. 32) is the best source of information. It includes procedure codes for the glucose testing supplies that Medicaid clients are eligible to receive.

It took two meetings with Health & Human Services Commission staff to get CNMs added to the list of providers, but we finally got it done. If you find yourself at an impasse with the Texas Medicaid Program, please contact Lynda@cnaptexas.org.  Sometimes CNAP can help resolve your problem, but we can’t help if we don’t know about it.