Physician and Professional Services

Definitions

Advanced Practice Registered Nurse (APRN): An individual licensed as a registered nurse by the Minnesota Board of Nursing and certified by a national nurse certification organization acceptable to the Minnesota Board of Nursing to practice as a Clinical Nurse Specialist (CNS), nurse anesthetist, nurse-midwife, or Nurse Practitioner (NP). The practice of advanced practice registered nursing also includes accepting referrals from, consulting with, cooperating with, or referring to all other types of health care providers, including but not limited to physicians, chiropractors, podiatrists, and dentists, provided that the APRN and the other provider are practicing within their scopes of practice as defined in state law. The APRN must practice within a health care system that provides for consultation, collaborative management, and referral as indicated by the health status of the patient.

Allergenic Extract: The refined injectable form of antigen either commercially prepared or refined in the physician’s office under his/her supervision.

Ambulatory Uterine Monitoring Device: Medical equipment designed to be used by the layperson to monitor uterine activity.

Anesthesiologist: A physician who specializes in anesthesiology and is board-certified as an anesthesiologist.

Anesthesiology: The practice of medicine dedicated to the relief of pain and total care of the surgical patient before, during, and after surgery.

Antigen: The raw form of pollen (venom, stinging insect, etc.), prior to refinement for administration to humans.

Certified Nurse Midwife (CNM): An individual licensed as a registered nurse (RN) by the Board of Nursing and certified by a national nurse certification organization acceptable to the Board of Nursing to practice as a nurse midwife.

Certified Nurse Midwife (CNM) Practice: The management of a member’s primary health care, including pregnancy, childbirth, during the postpartum period, care of the newborn, family planning, partner care management relating to sexual health, and gynecological care of women throughout their life. CNM practice includes ordering, performing, supervising, and interpreting most diagnostic studies; prescribing pharmacologic and non-pharmacologic therapies; and consulting with, collaborating with, or referring to other health care providers as warranted by the needs of the patient.

Certified Nurse Practitioner (CNP): Is certified for advanced registered nurse practice in a specific field or nurse practice.

Certified Nurse Practitioner (CNP) Practice: The provision of care including health promotion, disease prevention, health education, and counseling. CNP practice includes providing health assessment and screening activities as well as diagnosing, treating, and facilitating patients’ management of their acute and chronic illnesses and diseases. The scope of practice includes ordering, performing, supervising, and interpreting most diagnostic studies as well as prescribing pharmacologic and non-pharmacologic therapies; and consulting with, collaborating with, or referring to other health care providers as warranted by the needs of the patient. The CNP is certified for advanced registered nurse practice in a specific field of nurse practitioner practice.

Clinical Nurse Specialist (CNS) Practice: The provision of patient care in a particular specialty or subspecialty of advanced practice registered nursing within the context of collaborative management, and includes: (1) diagnosing illness and disease; (2) providing non-pharmacologic treatment, including psychotherapy; (3) promoting wellness; and (4) preventing illness and disease. The certified CNS is certified for advanced practice registered nursing in a specific field of CNS practice.

Certified Registered Nurse Anesthetist (CRNA): An advance practice registered nurse. CRNAs are registered nurses with a baccalaureate degree who have completed an additional 24 to 36 months of training in anesthesiology in an accredited program and are certified by the Council on Accreditation of Nurse Anesthetists, or the American Association of Nurse Anesthetists (AANA).

Collaborative Management: A mutually agreed upon plan between a CNP and one or more physicians or surgeons that designates the scope of collaboration necessary to manage the care of patients. The nurse practitioner and the one or more physicians must have experience in providing care to patients with the same or similar medical problems.

Consultation: When the treating physician or other qualified health care professional asks the advice or opinion of another physician or qualified health care professional.

Cosmetic Surgery: Cosmetic surgery is performed to reshape normal structures of the body in order to improve appearance and self-esteem. The procedure is done for decorative purposes rather than functional, medical, or mental health reasons. Cosmetic surgery is excluded from coverage.

Developmental Disability (DD) Screening Document: Assessment tool required for any person being admitted to an institution. This process is to be used to provide people with community service options in order to prevent admissions or to provide transition assistance in the event an admission cannot be avoided. If a person is admitted and requests RSC services, this process includes a means for assessing the member’s health, psychosocial, and functional strengths and needs, in addition to assisting the member to identify needed and available services.

Distant Site: The site where the physician or practitioner providing the professional service is located at the time the service is provided via a telecommunications system.

Enhanced Services: Services available to members identified as high-risk for an adverse pregnancy outcome. These services are reimbursed in addition to routine OB services. Enhanced services include high-risk antepartum management, care coordination, Prenatal Health Education I & II, prenatal nutrition education, and postpartum follow-up home visits.

Family Planning Agency: A family planning agency is an entity having a medical director that provides family planning services under the direction of a PrimeWest Health-enrolled physician. The medical director must ensure that the counseling and information on family planning are performed by trained personnel and according to accepted community standards.

Family Planning Services: Family planning health services include screening, testing, and counseling for sexually transmitted diseases/infections (STDs/STIs), such as HIV, when provided in conjunction with the voluntary planning of conception and childbearing and related to a member’s condition of fertility.

Family Planning Supply: A prescribed drug or contraceptive device ordered by a physician or other eligible provider with prescribing authority for treatment of a condition related to a family planning service.

Genetic Counselor or Geneticist: An individual who is board certified by the American Board of Genetic Counseling (ABGC).

High-Risk: A pregnant person who requires additional prenatal care services because of factors that increase the probability of a preterm delivery, a low birth weight infant, or an adverse birth outcome.

Hub Site: A medical facility telehealth site where the medical specialist is located.

Hysterectomy: A medically necessary procedure or operation for the purpose of removing the uterus.

Immunotherapy: The parenteral administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale to a dosage which is maintained as maintenance therapy.

Institutionalized Individual: An individual who is involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility (including a mental health or other facility for the care and treatment of mental illness), or confined under a voluntary commitment in a mental health or other facility for the care and treatment of mental illness.

Institutions: Includes hospitals and nursing facilities (NFs), including certified boarding care facilities (BCFs), Intermediate Care Facilities for the Developmentally Disabled (ICF/DDs), and Regional Treatment Centers (RTCs) providing inpatient services to members currently receiving Medical Assistance (Medicaid).

Investigative: Refer to Authorization Standards for Surgery, Including Cosmetic and Reconstructive Surgery section of this chapter.

Long-Term Care Consultation (LTCC) Screening Document: An assessment tool required for any member admitted to an institution. The screening is to provide community service options in order to prevent admissions or to provide transition assistance in the event an admission cannot be avoided. If a member is admitted and requests transition services, the screening includes a means for assessing a member’s health, psychosocial, and functional strengths and needs, in addition to assisting the member identify needed and available services.

Low Birth Weight: Birth weight less than 2,500 grams (5.5 pounds).

Mentally Incompetent Individual: An individual who is declared mentally incompetent by a Federal, State, or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes which include the ability to consent to sterilization. Note: A member who has a legal guardian is considered a mentally incompetent individual.

Nurse-Midwife Practice: The management of women’s primary health care, focusing on pregnancy, childbirth, the postpartum period, care of the newborn, and the family planning and gynecological needs of women and includes diagnosing and providing non-pharmacologic treatment within a system that provides for consultation, collaborative management, and referral as indicated by the health status of patients

Nurse Practitioner (NP) Practice: Practice within the context of collaborative management: (1) diagnosing, directly managing, and preventing acute and chronic illness and disease; and (2) promoting wellness, including providing non-pharmacologic treatment. The certified nurse practitioner (CNP) is certified for advanced registered nurse practitioner (ARNP) in a specific field of NP practice.

Originating Site: A site including but not limited to a health care facility at which a patient is located at the time health care services are provided to the patient by means of telehealth.

Personally Performed: To be considered personally performed, the anesthesiologist may not be involved in any other procedure or duties that take him/her out of the operating room. It should be assumed that if the anesthesiologist leaves the operating room, he/she is performing other duties. If the anesthesiologist leaves the operating room to perform any other duties, the anesthesia procedure may not be billed as personally performed.

Physician: A person who is licensed to provide health services within the scope of his/her profession under MN Stat. Chap. 147. For purposes of this section, a physician means a licensed doctor of medicine or osteopathy.

Physician Assistant (PA): A person registered pursuant to MN Stat. Chap. 147A who is qualified by academic or practical training or both to provide patient services as specified in MN Stat. Chap. 147A under the supervision of a supervising physician.

Physician Extender: PA or APRN who chooses not to enroll with PrimeWest Health, genetic counselor, registered nurse, licensed acupuncturist, or pharmacist who is:

1. Employed by the physician provider;
2. Employed by the same provider organization that employs the physician; or
3. Supervised by a physician.

Plastic Surgery: The alteration, replacement, or restoration of visible parts of the body performed to correct a structural defect or for cosmetic effect.

Prescribing: The act of generating a prescription for the preparation of, use of, or manner of using a drug or therapeutic device in accordance with Minnesota law. Prescribing does not include recommending the use of a drug or therapeutic device that is not required by the Food and Drug Administration (FDA) to meet the labeling requirement for prescription drugs and devices.

Preterm Birth: Birth before the gestational age of 38 weeks.

Preventive Health Service: A health service provided to a patient to avoid or minimize the occurrence or recurrence of illness, infection, disability, or other health condition.

Professional Services: Physician ordered allergen immunotherapy and services either performed by the physician or qualified personnel under the physician.

Reconstructive Surgery: Performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Procedures are done in order to replace, rebuild, restore, or to create one or more body parts or functions.

Registered Nurse (RN): A nurse licensed under and within the scope of Minnesota Statutes.

Registered Nurse Anesthetist Practice: The provision of anesthesia care and related services within the context of collaborative management, including selecting, obtaining, and administering drugs and therapeutic devices to facilitate diagnostic, therapeutic, and surgical procedures upon request, assignment, or referral by a patient’s physician, dentist, or podiatrist.

Relocation Service Coordination (RSC): A type of targeted case management for members residing in eligible institutions who want to move into the community. RSC helps a member who resides in an eligible institution to plan, arrange, and gain access to needed medical, social, educational, financial, housing, and other services and supports that are necessary to move from an eligible institution to the community.

Risk Assessment: A standardized prenatal assessment tool, or equivalent, for identification of the medical, genetic, lifestyle, and psychosocial factors that determine a member is high-risk for  an adverse birth outcome.

Spoke Site: A remote site where the referring health professional and patient are located.

SRNA: Student Registered Nurse Anesthetist

Sterilization: Any medical procedure, treatment, or operation for the purpose of rendering an individual permanently incapable of reproducing.

“Store and Forward”: The asynchronous transmission of medical information to be reviewed at a later time by a physician or practitioner at the distant site. Medical information may include, but is not limited to, video clips, still images, X-rays, magnetic resonance imaging (MRIs), EKGs, laboratory results, audio clips, and text. The physician at the distant site reviews the case without the patient being present. Store and forward substitutes for an interactive encounter with the patient present; the patient is not present in real-time.

Targeted Case Management (TCM): Services that assist a member eligible under the plan in gaining access to needed medical, social, educational, and other services.

Telehealth: The delivery of health care services or consultations through the use of real time two-way interactive audio and visual communications to provide or support health care delivery and facilitate the assessment, diagnosis, consultation, treatment, education, and care management of a patient's health care. Telehealth includes the application of secure video conferencing, store-and-forward technology, and synchronous interactions between a patient located at an originating site and a health care provider located at a distant site. Until July 1, 2025, telehealth also includes audio-only communication between a health care provider and a patient in accordance with MN Stat. 62A.673, subd. 6 (b). Telehealth does not include communication between health care providers that consists solely of a telephone conversation, email, or facsimile transmission. Telehealth does not include communication between a health care provider and a patient that consists solely of an email or facsimile transmission. Telehealth does not include telemonitoring services.

Two-Way Interactive Video: A type of technology that permits a “real-time” consultation to take place. This is used when a consultation involving the patient, the primary caregiver, and a specialist is medically necessary. Video-conferencing equipment at two different locations permits a live non-face-to-face consultation to take place.

Updated_12/03/2024