Professional Roles and Reimbursement

A comprehensive set of Q&A flashcards covering NP origins, regulation, practice, reimbursement, coding, and healthcare quality concepts from the notes.

Who started the first NP program, where, and when?

Loretta C. Ford and Henry K. Silver; University of Colorado; 1965; began as a certificate program and later became a master’s program in the 1970s.

Where did the first NPs practice and why?

In economically disadvantaged rural areas with a severe shortage of primary care physicians.

From where does an NP’s legal right to practice originate?

From the state nursing practice act enacted by the state legislature.

What is the role of the State Board of Nursing (SBON)?

Enforces the state’s nursing practice act; licenses, monitors, disciplines nurses; can revoke a license after formal hearings.

What is title protection in nursing?

Professional designations (RN, NP, APRN) are protected by law to prevent unlicensed use and protect the public.

What is the difference between licensure and certification?

Licensure is a legal requirement to practice, obtained through the SBON; certification is usually voluntary and often required for licensure in many states.

What standards govern nursing practice and who publishes NP standards?

Standards of Practice and Standards of Professional Performance; published by the ANA; NP Standards of Practice published by the AANP; other specialty groups publish their own standards.

What is a Collaborative Practice Agreement (CPA)?

A written agreement between a physician and an NP outlining the NP’s role and responsibilities; kept at the practice site; often requires annual review.

Which professionals can sign collaborative practice agreements?

Physicians (MDs), osteopaths (DOs), and dentists (DMDs/DDSs); chiropractors and naturopaths are generally not eligible.

Do NPs have prescriptive authority in the United States?

Yes—all 50 states grant prescriptive authority, including controlled substances; scope varies by state.

What details are typically on an NP prescription pad?

NP’s name, designation, and license number; practice setting address/phone; listing multiple sites if applicable; DEA number is optional and usually omitted for noncontrolled substances.

What are Schedule II drugs and their prescribing rules?

High-abuse-potential drugs that cannot be called in; must be on tamper-resistant pads; must be signed by the prescriber; examples include morphine, oxycodone, fentanyl, codeine, amphetamines.

What is E-Prescribing?

Electronic transmission of prescriptions directly to the pharmacy; preferred method for Medicare/Medicaid.

What is the difference between ICD-11 and CPT codes?

ICD-11 codes identify diagnoses; CPT codes identify procedures/services; both are required for billing.

What are Evaluation and Management (E&M) codes used for?

Billing codes for patient visits; based on time or level of service; essential for reimbursement.

What is Telehealth and how does it differ from Telemedicine?

Telehealth is a broad term for services and technologies to extend care; telemedicine is a subset involving remote clinical services via secure audio/video.

What did the HITECH Act leverage for health IT?

Incentives to adopt electronic health records (EHRs); penalties for non-adoption after 2015; strengthened HIPAA enforcement.

What is the purpose of the Affordable Care Act (ACA)?

Expanded health insurance coverage, prohibited denial for preexisting conditions, allowed dependents up to age 26 to remain on parental plans.

What is COBRA coverage?

Continuation of employer-sponsored health insurance for a fixed period (commonly 18 months; up to 36 months in some cases) after job loss.

What does Medicare Part A cover, and what does it not cover?

Covers inpatient hospitalization, hospice, home health, and SNF care; does not pay for custodial/nongovernmental care.

What does Medicare Part B cover and what are its limitations?

Outpatient services, labs, DME, some screenings, and preventive services; voluntary with premiums; does not cover most eyeglasses, hearing aids, or most dental care.

What are Medicare Part C and Part D?

Part C (Medicare Advantage) combines A and B coverage (and sometimes prescription drugs); Part D covers prescription drugs via private plans with formulary limitations.

What is Medicaid and who does it serve?

A federal–state program (Title XIX) that provides health coverage for low-income individuals and families; includes mental health and SUD services; CHIP covers uninsured children and pregnant individuals.

What is the Patient-Centered Medical Home (PCMH)?

A primary care delivery model centering care on the patient and family with coordinated, team-based care and 24/7 access.

What are the Health Belief Model (HBM) concepts?

People are more likely to adopt healthier behaviors if they feel susceptible, perceive seriousness, see benefits, and have self-efficacy, with barriers modified by demographics and social factors.

What is Bowen’s Family Systems Theory?

All parts of a family system are interrelated; dysfunction in one member affects the whole system; other members may compensate or experience stress.

What are the five stages of the Transtheoretical Model (Stages of Change)?

Precontemplation, Contemplation, Preparation, Action, Maintenance; developed by Prochaska and DiClemente to describe steps in behavioral change.

What is Case Management in healthcare?

Experienced RNs coordinate outpatient management of chronic illnesses, often via telephone.

What is Quality Improvement (QI) in healthcare?

Systematic monitoring and measurement of outcomes to identify problems and implement improvements to care quality and patient safety.

What is Risk Management in healthcare?

Process to identify risky practices and minimize adverse patient outcomes and liability, focusing on areas like medication errors, infections, patient identification, and falls.

What is Accreditation and the role of The Joint Commission (TJC)?

Accreditation is voluntary and evaluates qualifications; TJC accredits healthcare organizations to enhance quality and safety.

What is a Sentinel Event (SE) and what is RCA?

An SE is a patient safety event causing death or serious harm; organizations conduct a root cause analysis (RCA) to identify system factors and implement corrective actions.

What is Outcomes Analysis in healthcare?

Analysis and tracking of patient outcomes using measures such as surveys to assess care quality.