Order No. 28168
APPROVAL TO INCLUDE CRNA SERVICE AS AN OPTIONAL SERVICE UNDER
THE INDIGENT HEALTH CARE PROGRAM
On this the 14th day of July, 2003 upon motion made by Commissioner Williams and
seconded by Commissioner Nicholson, the Court unanimously approved by a vote 4-0-
0 to include CRNA services as an Optional Service under the Indigent Health Care
Program, and authorize County Judge to sign the same.
COMMISSIONERS' COURT AGENDA REQUEST
~~ `~~ l ~ ~
PLEASE FURNISH ONE ORIGINAL AND NINE COPIES OF THIS REOUEST AND DOCUMENTS TO BE
REVIEWED BY THE COURT.
MADE BY: Pat Tinley OFFICE: Coun Jud
MEETING DATE: July 14 2003 TIME PREFERRED:
SUBJECT: (PLEASE BE SPECIFIC)
Consider and discuss approval of the inclusion of CRNA services as an Optional Service under
the Indigent Health Care Program, and authorize County Judge to request approval of such
inclusion by Texas Department of Health.
EXECUTIVE SESSION REQUESTED: (PLEASE STATE REASON)
NAME OF PERSON ADDRESSING THE COURT
ESTIMATED LENGTH OF PRESENTATION:
IF PERSONNEL MATTER -NAME OF EMPLOYEE:
County Judge
Time for submitting this request for Court to assure that the matter is posted in accordance with Title 5, Chapter
551 and 552, Government Code, is as follows:
Meeting scheduled for Mondays
THIS REQUEST RECEIVED BY:
THIS REQUEST RECEIVED ON:
5:00 P.M. previous Tuesday.

All Agenda Requests will be screened by the County Judge's Office to determine if adequate information has been
prepared for the Court's formal consideration and action at time of Court Meetings. Your cooperation will be
appreciated and contribute towards you request being addressed at the earliest opportunity. See Agenda Request Rules
Adopted by Commissioners' Court.
)Ct-30-02 02:44P Anesthesia Associates 210 896-1363 P.O1
~p ., ~J 1~C~1~
October 29, 2002
~s~ ~6~5
The Honorable Fred Henneke
700 Main St
Kerrville TX 78028
Dear Judge Henneke:
The purpose of this letter is to request your assistance in add.
group is having with the Kerr County Indigent Health Care 1
charges for anesthesia services provided by CRNA (Certified
are being denied and remaining unpaid.
Anesthesia Associates is the medical group that provides anesthesia
Peterson Memorial Hospital and Peterson Regional Ambulatory C.
have four physician anesthesiologists and three CRNAs working in
are employees of our group. The physician anesthesiologists and C]
the team care framework although the nurses are not medically dir
in the strictest sense as defined by Medicare. In genera[ , anesthesia
performed by either the physician or the CRNA and we bill in the ~
CRNA providing the service.
The following health plans and programs fully approve and pay
provided by CRNA acting alone:
Medicare
Medicaid
Blue Cross Blue Shield
Workers Compensation
Texas Rehabilitation Commission
Texas CHIP Program
Commercial and PPO Plans too numerous to
In fact, in routinely dealing with almost 400 health plans aad p
encounter a plan that does not approve and pay for the CRNA
a problem our medical
n. Specifically, our
>red Nurse Anesthetist)
care and services at Sid
re Center. We presently
cur group. The CRNAs
NAs work together in
acted by the physicians
services are personally
sme of the physician or
anesthesia services
it is highly unusual to
]ct-30-02 02 .44P AnestF-~es is Associates 210 896- 1363 P . 02
Pagc Two
October 29, 2002
Unfortunately, it has come to our attention that the Kerr County
program will not pay for the CRNA service. Enclosed is a copy of
this issue obtained from the administrator of the program - Vericl
We are requesting that the charges for anesthesia personally pert
approved and paid by the Kerr County Indigent Health Care Pro
universal standard in the anesthesia and medical payor business.
A possible solution to the problem is for Anesthesia Associates to
name of a physician, with the disclosure to you and the County th;
personally providing the service but as an employee of Anesthesia
framework of the anesthesia team concept of care.
To provide further information to you, I am also enclosing a copy
from the program. The claim reports our standard rate, but let a
approved by the indigent program, which mirrors Medicaid, the 1
be approximately $ 340 fora 3 hour surgery.
Sincerely,
.gent Health Care
manual addressing
by CRNA be
as this is virtually a
l the charge in the
the CRNA is
and within the
f a claim and denial
advise yon that if
yment amount would
John Massey
Practice Manager, Anesthesia Associates
FORM 120
Page 1
CIHCP Optional Service Request
Please read optional service definitions on the back of this page.
Types of Optional Services: (circle the numbers of the services your county wishes to provide)
1.	Advanced Practice Nurse (APN)
2.	Ambulatory Surgical Center (ASC)
3.	Certified Nurse Midwife (CNM)
4.	Certified Registered Nurse Anesthetist (CRNA)
5.	Colostomy Medical Supplies and/or Equipment (colostomy bags/pouches, cleansing irrigation kits, paste
	or powder, and wafers)
6.	Counseling Services: (check the ones your county wishes to provide)
	A. Licensed Professional Counselor (LPC)
	B. Licensed Marriage Family Therapist (LMFT)
	C. Licensed Master Social Worker-Advanced Clinical Practitioner (LMSW-ACP)
	D. Ph.D. Clinical Psychologist
7.	Dental Care (annual routine exam, annual routine cleaning, one set of annual x-rays, and the least costly
	service for emergency dental conditions for the removal or filling of a tooth due to abscess, infection, or
	extreme pain)
8.	Diabetic Supplies and/or Equipment (syringes, lancets, test strips, alcohol prep pads, glucometers, humulin
	pens, and the needles required for the humulin pens.)
9.	Durable Medical Equipment: (check the ones your county wishes to provide)
	A. Crutches D. Standard wheel chairs G. Home oxygen equipment
	B. Canes E. Hospital beds H. Blood pressure measuring appliances
	C. Walkers F. TENS units
10.	Federally Qualified Health Center (FQHC)
11.	Home and Community Health Care
12.	Physician Assistant (PA)
13.	Vision Care (one exam by refraction and one pair of prescribed glasses every 24 months)
14.	Emergency Medical Services (ground transportation only)
CHANGE [Check here if your county wishes to discontinue any of the optional services that you are currently
providing this state fiscal year. Circle the optional services above that you will continue providing.
Complete and submit this forma
Ju1y 14, 2003
`- Signat re of County Judge/Designee Date
Name:
Pat Time	Title:
Kerr County Judge
County:
Kerx County	Mailing Address: 700 Main
Phone Number (Include area code.):	City/State2ip:
Texas 78028
Kerrville
830-792-2211	,
CIHCP 02-6
November, 2002
FORM 120
Page 2
CIHCP Optional Service Definitions
All of these optional services will count towards the client's $30, 000 or 30 day inpatient hospitaUskilled nursing limitation.
Some of these services are not SSl-Medicaid reimbursable through the Indigent Health Care Division of TDH.
1. Advanced Practice Nurse (APN) services must be medically necessary and provided within the scope of practice of an APN and covered by the
Texas Medicaid Program when provided by a licensed physiaan.
2. Ambulatory Surgical Center (ASC) services must be provided in a Title XIXMecticaid-enrolled ASC, and are limited to items and services furnished in
reference to an ambulatory surgical procedure, including those services on the HCFA approved list and selected Medicaid-only procedures.
3. Certified Nurse Midwife (CNM) services must be medically necessary, provided within the scope of practice of a CNM, and covered by the Texas
Medicaid Program when provided by a licensed physician.
4. Certified Registered Nurse Anesthetist (CRNA) services must be medically necessary; provided within the scope of practice of a CRNA; prescribed
and supervised by a physician, dentist, or podiatrist who must be licensed in the state in which they practice.
5. Colostomy medical supplies andlor equipment must be medically necessary and prescribed by a physician or an APN ff this is within the scope of
their practice in aacordance with the standards established by the Board of Nurse Examiners and published in 22 TAC §221.13. Items covered are
colostomy bags/pouches, cleansing irrigation kits, paste or powder, and wafers. The county may require the supplier to receive prior authorization.
6. Counseling (psychotherapy) services must be medically necessary based on a referral from a physiaan or an APN if this is within the scope of their
practice in accordance with the standards established by the Board of Nurse Examiners and published in 22 TAC §221.13. Psychotherapy services must
be provided by a Licensed Professional Counselor (LPC), Licensed Marriage Family Therapist (LMFT), Licensed Master Social Worker-Advanced Clinical
Practitioner (laulSW-ACP), or a Ph.D. Psychologist.
7. Dental care must be medically necessary and provided by a DDS, DMD, or DDM. Items covered are an annual routine exam, annual routine cleaning,
one set of annual x-rays, and the least costly service for emergency dental conditions for the removal or filling of a tooth due to abscess, infection, or
extreme pain. The county may require prior authorization.
8. Diabetic supplies andlor equipment must be medically necessary and prescribed by a physician or an APN if this is within the scope of their practice
in accordance with the standards established by the Board of Nurse Examiners and published in 22 TAC §221.13. Items covered are syringes, lancets,
test strips, alcohol prep pads, gluoometers, humulin pens, and the needles required for the humulin pens. The county may require the supplier to receive
prior authorization. These do NOT count as one of the three prescribed drugs per month.
9. Durable medical equipment must be medically necessary; meet the MedicareMledicaid requirements; and be provided under a written, signed and
dated prescription from a physician or an APN if this is within the scope of their practice in accordance with the standards established by the Board of
Nurse Examiners and published in 22 TAC §221.13. Items may be purchased or rented, whichever is least costly. Items covered are crutches, canes,
walkers, standard wheel chairs, hospital beds, TENS units, home oxygen equipment (including masks, oxygen hose, and nebulizers), and reasonable and
appropriate appliances for measuring blood pressure. The county may require the supplier to receive prior authorization. These do NOT count as one of
three prescribed drugs per month.
10. Federally Qualified Health Center (FQHC) services must be provided in an approved FQHC by a physician, physician's assistant, nurse
practitioner, clinical psychologist, or clinical social worker.
11. Home and community health care must be medically necessary; meet the MedicarelMedicaid requirements; and be provided by a certified home
health agency. A plan of care must be recommended, signed, and dated by the recipient's attending physiaan prior to care being given. Items covered
are RN. visits for skilled nursing observation, assessment, evaluation, and treatment provided by a physiaan who speafically requests the R.N. visit for
this purpose. A home health aide to assist with administering medication is also covered. Visits made for performing housekeeping services are not
covered. A county may require prior authorization.
12. Physician Assistant (PA) services must be medically necessary and provided by a PA under the direction of an M.D. or a D.O. and must be billed by
and paid to the supervising physiaan.
13. Vlslon care covers 1 exam by refraction and 1 pair of prescribed glasses every 24 months that meet Medicaid criteria.
14. Emergency medical service covers ground transportation only for medically necessary life-threatening conditions.
CIHCP 02-6
November, 2002
06!18/2003 11:21 830-792-2238
owM+Y ~.~
1~ 21E~nece
C,aN.~mnnats Co~t~r
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WIUL1~1 "Q711" ~AJNrti, t~. Z
1~11ttf1tAM LE1Z. ~-. 3
f-+ir. John Massey
Fractiat MaiatKr,
Ar2cxthesi2e Ass~ociatcs, LLh
420 Water Stt~oet, Suite 10513
Kerrviik, Texas 78028
itF,: CRNA Reireburstticxrtt
Dear Mr. Masser:
KERR CAUNTY AUDITOR PAGE 02
M
THE COUNTY COURT
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Kt~rc courrnr, rags	
711101+7~w 2(sawsts.Tt:xxAS7iEl2i	G>~
t a:1aw(1) 712.221 ~	1.wK~rr PrefR
• Fax: fi>01 742.2111	
R•MA~I: R[ncoaMK wa	Caut,7Rt Qc7f1ROMATOR
	THFR StYV>e.
hiovamba 18, 2UU2
Thsnk you &x your letter datrd Ckii~t?er 24, 2f~2, regarding the im.iusion of CRNAs in tho Kerr Cnurtity
indigent Health Care progl-am.
After taoicit-g inw the issut, [have detaaunad drat the issut of inclusiar of CttNA services in the County
lrtdigcnt Ha~lth Care program falls undar it~c umlxdla of Optional Savae:1. for whatevex t+eaaon, the County's
contract with the Texas Dcpartnm~t of t Icalth does not inctudc such C)ptionai 5ervias. Theaefoce, scnriccx by
CI{NAs are not ctigible utrdcr the carrcnt prc~gra2n
However, the contract bctwetrl the Texas Depart tent of Health nerd Kerr Cotteity can be smrAdud to include
such Optional Soviets. Urtfortunatcly, such acnend:t~ctx will only be offeetivc at the start of the State's rtext
fiscal year, a< Scpt~emba I, 20(la. As such, there is lithe that can be aoeamplishoc} at ibis tithe.
tsy copy Qf Ihis teller, 1 art notifying County lodger-L'•tect Pat Tirdry as vwell as Judie $tUdsoc, the Indigent Hcaltfi
Care Coordinator, of this sitwtio><1 abng with my rac~xnmendaticu2 that ttie contract with'FDH be ametldod neln
summa io include such Optional Service.
lfyc>u have; any questic~rts, phase givL. [11C a call.
Sintxr'dy yours
~~
'rod Hennclcc
Kerr Cow+ty lodge
Cc: CotrattissicxRCrs
Cc+unty ludgo-L•}ari Fat Tinley
ladle BlodSOe