Nurse anesthetists would be on equal footing with anesthesiologists when it comes to treating pain management patients if a proposed Medicare rule becomes law. In what's shaping up to be a significant scope-of-practice victory, CRNAs could request independent medical privileges to diagnose and treat pain management patients in states where they may furnish them, and receive 100% of the reimbursement.

If approved, the CMS ruling would reverse an April 2011 decision by Noridian, the Medicare contractor for most of the Western United States, to stop reimbursing CRNAs for pain management services. (Noridian — and other payors that followed suit — would only reimburse CRNAs for pain management services that were "incident to" the services of a physician at 85% of standard.) This proposed new rule would standardize reimbursement throughout the CMS system as long as pain management was within the scope of practice in any particular state.

While the proposal would clarify when Medicare would pay for interventional pain management services provided by CRNAs, many see it as a win for CRNAs in their turf war against anesthesiologists.

"There is an assault on advanced practice nursing by organized medicine" says Jay Horowitz, CRNA, of Quality Anesthesia Care Corp. in Sarasota, Fla. "CRNAs are fully capable and in most states legally able to provide these pain care procedures."

The American Society of Interventional Pain Physicians "strongly objects to any consideration of CRNA's request to practice outside the field of anesthesia services, specifically in the field of medicine defined as Interventional Pain Management," says Laxmaiah Manchikanti, MD, chairman and CEO of ASIPP. "CRNAs are not qualified to perform these procedures with or without supervision. We strenuously oppose these regulations."

Facet injections, imaging guidance and other interventional pain management techniques are not part of CRNA anesthesia training, adds Dr. Manchikanti. "CRNAs are demanding to be paid precisely the same as board-certified IPM doctors for procedures that are disallowed by many national insurance companies if performed by board certified anesthesiologists who do not have additional board certification in pain management," he says.

Dan O'Connor