News & Alerts

ICD-10 Delayed! *again*

ICD-10 DELAYED  (again)- the implementation of ICD-10 will not start till 10/01/2015.  The AAPA suggest that this maybe an opportunity to listen, and with a relaxed  frame of mind, re view this informative video regarding ICD-10 coding basics.  This can be found at
  • This may be a great time to reorganize and re-prioritize her documentationIt may be beneficial to ask administrator or coder to run a list of the 50 most common ICD-9 codes that you use and then research and learn the ICD-10 equivalent.
  • And continue to watch and listen for coding updates for Medicare.

CMS Eliminates PA Practice Barriers in Rural Areas

By Michael Powe

May 8, 2014

The Centers for Medicare & Medicaid Services (CMS) issued a rule on May 7 that provides regulatory relief for PAs and physicians who deliver care in rural communities. This regulatory change advances a federal initiative to remove burdensome and unnecessary regulations.

The final rule, for which AAPA advocated, eliminates a requirement for a physician to be physically on site once every two weeks at certified rural health clinics, federally qualified health centers and critical access hospitals (CAHs). PAs will continue to follow state law and facility policies.

Two additional issues in the rule include:

  • Confirmation of existing CMS policy that PAs may be members of a hospital’s medical staff.
  • Elimination of a requirement that CAH physicians review outpatient medical records at least bi-weekly for patients treated by PAs (or NPs). CMS will now defer to state law on this issue.

Ensuring patients receive timely access to medically necessary, high-quality care is the goal behind the federal effort to remove regulations that are outdated, don’t lead to improved patient care or are no longer reflective of the enhanced manner in which PAs deliver care.

For additional information contact Michael Powe, AAPA vice president of reimbursement and professional advocacy, at This email address is being protected from spambots. You need JavaScript enabled to view it. .

Nebraska Hospital Association Sponsors Health Careers



Your health care career is within reach

Health care is a growing and technologically advanced industry. Hospitals across the country, especially in rural states like Nebraska, are experiencing a severe shortage of health care professionals.

There are more than 100 different health care professions and it is one of the fastest growing fields of occupation.

Do you have the heart and drive it takes to make a difference through a health care career?

The work isn’t easy, but the rewards last a lifetime and help improve the quality of life for others Nebraska’s hospitals are dedicated to improving the health and well-being of their patients and their communities.

Providers are privileged to improve the health and welfare of every person that is within their reach, invest in the future of health care's workforce and serve the health needs of the communities of Nebraska.

The NHA is accepting applications for the Graduate Studies Tuition Aid Program and the Undergraduate Health Care Career Scholarship Program.

Download brochure (Important! Revised eligibility criteria)

Download application form

Download reference form (print 3)

For more information, contact Kim Larson, director of marketing, at 402/742-8143 or This email address is being protected from spambots. You need JavaScript enabled to view it. .

Deadline for submission is May 23, 2014.



Precepting Students

Within a year of starting my first job as a Physician Assistant I was asked to precept a PA student. My first thoughts were along the lines of; “I just graduated and started this job and now I am going to try and teach someone else?” I would like to go back and “redo” those first few rotations as I am sure I could have taught them more and given then a better clinic experience. Now, after 6 years of precepting, I finally feel as though I have a better understanding of what makes a good preceptor. There are three main reasons that I have continued to precept students; furthering the PA profession, furthering my education, and furthering the education of the PA student. Any time a PA student comes into our office and interacts with patients, family members, and/or staff they are exposing the PA profession and educating others about what we do. There is no way that our profession would be where it is today without all of the PAs who have volunteered their time and talents to be a preceptor for students. A benefit I receive as I continue to precept students is learning something from each one, whether it be the answer to a question that we have to look up together or an update they have learned in one of their lectures. Teaching students will always keep you on your toes. Of course one cannot forget what preceptors are doing for the education of the students themselves. Try to imagine being the PA you are today without the hands on rotations that you were able to participate in. Thank you to those who already serve as preceptors and if you do not, I encourage you to think about starting, as the benefits will be great for the student, teacher, and profession.


Chelsie Doane, PA-C

2014 NAPA President Elect


New Guidelines for Treating Hypertensive Patients

In the United States, 78 million (1 out of 3) adults have high blood pressure (BP). Early detection and appropriate treatment of hypertension is important to reduce the risks of other progressive diseases such as stoke, renal failure, myocardial infarction, and death. In 2003, the Seventh Joint National Committee (JNC 7) issued a report with guidelines including changes in the categorization and definition of hypertension with recommended lifestyle modifications and pharmacologic strategies for treatment. These hypertension definitions based off of systolic blood pressure (SBP) and diastolic blood pressure (DBP) from JNC7 were simplified to 4 categories as follows:

· Normal blood pressure: SBP <120 mmHg and DBP <80mmHg
· Prehypertension: SBP 120-139 mmHg or DBP 80-89 mmHg
· Stage I hypertension: SBP 140-159 mmHg or DBP 90-99 mmHg
· Stage II hypertension: SBP ≥160 mmHg or DBP ≥100 mmHg

Last month, the Eighth Joint National Committee (JNC 8) published a report in the Journal of American Medical Association (JAMA) on evidence-based guidelines for the management of high BP in adults. During the literature review process, these recommendations were guided by three BP management questions:

· In adults with hypertension, does initiating antihypertensive pharmacologic therapy at specific BP thresholds improve health outcomes?
· In adults with hypertension, does treatment with antihypertensive pharmacologic therapy to a specified BP goal lead to improvements in health outcomes?
· In adults with hypertension, do various antihypertensive drugs or drug classes differ in comparative benefits and harms on specific outcomes?

JNC 8 issued nine recommendations concerning thresholds and goals for BP treatment and selection of antihypertensive medications and a summary for starting and adding antihypertensive drugs. These recommendations were assigned a score for both the strength of the recommendation and an evidence quality rating of each recommendation. The nine recommendations can be summarized into the following points:

· Patients 60 years or over, start treatment at SBP ≥ 150 mmHg or DPB ≥90 mmHg and work towards a goal lower than that threshold.
· In patients <60 yearswithout major comorbidities and patients >18 years with chronic kidney disease (CKD) or diabetes, treatment initiation and goals should be 140/90 mmHg.
· In nonblack patients (including diabetics), initial treatment should includethiazide-type diuretic, calcium channel blocker (CCB), angiotensin- converting enzyme inhibitor (ACE inhibitor), or angiotensinogen receptor blocker (ARB).
· In general black patient population (including diabetes), initial treatment should include thiazide-type diuretic or CCB.
· In patients >18 years with CKD, initial or add-on therapy should be an ACE inhibitor or ARB, regardless of race or diabetes status to improve kidney outcomes.
· HTN treatment is to attain and maintain goal BP. If goal BP not reached within a month of treatment, increase dose or add second drug and use up to 3 drugs from above recommendations. Do not use an ACEI and an ARB together in same patient. If target BP cannot be reached, referral to specialist maybe indicated.

Along with these guidelines, lifestyle modifications such as weight control through physical activity and a healthy diet should not be underestimated. JNC 8 included a convenient HTN guideline Management Algorithm in the article to be utilized by clinicians. For full free access to the JNC8 article on HTN management guidelines please visit

Submitted by Jessica Taylor, PA-S


Are You Updated?

shutterstock 48217207Have you moved recently?  Have you changed practice locations?  Have you gotten a new job?  If so, did you update you NPI number with Medicare?  Every time a PA gets a new place of employment or changes jobs you need to update your information with Medicare (updating your state license information doesn't update your information with Medicare).  Go to or call 800-465-3203 for help updating your information.

The Use of Fluoride to Control Dental Caries

The Use of Fluoride to Control Dental Caries in the Pediatric Population

The use of fluoride has been a major factor in the decline in the prevalence and severity of dental caries in the U.S.  When used appropriately, fluoride is both safe and effective in preventing and controlling dental caries.  Both healthcare professionals and the public need guidance on selecting the best way to provide and receive fluoride.

According to the American Academy of Pediatric Dentistry, 25% of our nation’s children have 80% of the cavities and this is largely due to the consumption of bottled water versus tap water in certain patient populations.  Water fluoridation is still the number one most cost effective way to prevent tooth decay.  This is because fluoride decreases tooth decay by as much as 70%. In cases of early cavities, fluoride can actually reverse the decay.  Fluoride encourages mineralization and strengthening of weakened areas of tooth enamel. 

Because frequent exposure to small amounts of fluoride each day will best reduce the risk for dental caries in all age groups, the CDC recommends that all persons drink water with optimal fluoride concentration and brush their teeth twice daily with fluoride toothpaste.  For persons at high risk for dental caries, additional fluoride measures may be needed.  Measured use of fluoride is particularly appropriate during the time of anterior tooth enamel development (under the age of 7).

According to the CDC, the goal in the use of fluoride should be to achieve maximum protection against dental caries while using resources efficiently to reduce the likelihood of enamel fluorosis (which is a staining of the teeth).

“Smiles For Life” is a national oral health curriculum that aims to build the capacity of primary care providers to carry out oral health throughout the lifespan.  Because fluoride not only helps prevent tooth decay, 45 state Medicaid programs now reimburse PCPs for applying fluoride varnish to young children’s teeth as a way to cure beginning cavies and buy time until children can be seen by a dentist who accepts Medicaid patients. 

It is also well known that babies can catch cavities from their caregivers and this should be addressed at all prenatal and at all well child visits.  In 71% of cases of dental caries, their mother is the source.  The better mom’s oral health, the less chance baby will have problems.  Cavity causing bacteria, Streptococcus Mutans, can be transmitted before teeth erupt.   It is important to tell parents to avoid putting their baby’s pacifiers in their own mouths, and to avoid sharing bottles or pacifiers with other children.   

Thirty percent of communities in the U.S. do not have fluoride in the public water supply so it is important to address this with your patients as well.  Any city utilities department can give you the testing information every few months which is measured in parts per million.  From that, one can determine how much supplemental oral fluoride is needed for children under the age of 7.

According to the American Academy of Pediatric Dentistry and the American Academy of Pediatrics, these guidelines should be used with pediatric patients:

$11.       Wean infant from bottle at 1 year of age.

$12.       All children should have their first dental examination by 1 year of age.

$13.       Never dip pacifier into anything sweet or clean pacifier with parent’s saliva or share with other children.

$14.       Do not allow children to fall asleep drinking a bottle.

$15.       Never put anything but water in a baby’s bottle if the baby needs to fall asleep with a bottle.

$16.       Brush gums and teeth twice daily.

$17.       Stop pacifier usage before the age of 3.

$18.       Use supplemental fluoride if needed until the age of 6.

$19.       Although children should be encouraged to learn to brush, parents should brush their children’s teeth until they are about 6 years of age or can write cursive.  This is due largely to the inability for young children to have the coordination to brush effectively.

The American Dental Association, the American Academy of Pediatrics, and the American Academy of Pediatric Dentistry all that parents to schedule their children’s first dental appointment by their first birthday. 

Adoption of the recommendations from the CDC and dental academies can further reduce dental caries in the U.S. and save public and private resources.  Brush Up on further recommendations for your practice at

Submitted by Dara Schroeder, PA-C

PA Hospice and Other Provisions Included in SGR Reform Proposals


With a nearly 24 percent Medicare payment cut scheduled to take place Jan. 1, Congress is poised to override the spending target determined by Medicare’s sustainable growth rate (SGR) formula and apply a 0.5 percent increase for payments to healthcare professionals through April 1, 2014. The three-month SGR patch was passed by the U.S. House of Representatives on Dec. 12 as part of the budget agreement for federal discretionary spending levels for fiscal years 2014 and 2015. The U.S. Senate is expected to take up the budget agreement, along with the SGR patch, this week.

Meanwhile, both the House and Senate continue to move forward with bipartisan legislation to repeal the SGR and reform Medicare’s payment system. The House Committee on Energy and Commerce was the first committee to pass legislation to repeal and replace the SGR in July. On Dec. 12, the House Committee on Ways and Means and the Senate Finance Committee followed suit. All three bills repeal the SGR, replacing it with a payment system that moves away from fee-for-service and moves toward a new value-based performance (VBP) program and provides incentives to develop alternative payment models (APM), such as medical homes, accountable care organizations and bundled payments.

Payment for fee-for-service would be frozen for 10 years with an increase of 1 percent in 2024. The VBP program would take into account quality, resource use, and clinical practice improvements and apply to payments for items and services furnished after Jan. 1, 2017. The APM incentives would begin in 2016.

PAs are treated in the same way as physicians and advanced practice nurses in the fee-for-service, VBP and APM programs. Additionally, PAs, physicians and advance practice nurses are eligible to provide chronic care management through the SGR reform bills. The Ways and Means Committee passed an SGR bill by a 39-0 vote, but it did not allow any amendments to the bill. The Senate Finance Committee included several scheduled amendments into the “chairman’s mark,” the legislation to be considered by the committee.

Among those amendments included in the mark, and subsequently passed by the committee, were:

  • An amendment sponsored by Sens. Mike Enzi (R-WY) and Tom Carper (D-DE) to amend Medicare to allow PAs to provide and manage hospice care for Medicare beneficiaries
  • An amendment offered by Sens. John Thune (R-SD), Michael Bennet (D-CO), Mike Enzi (R-WY) and Pat Roberts (R-KS) clarifying that general supervision by a physician or nonphysician practitioner is allowed at critical access hospitals (CAHs) for payment of therapeutic hospital outpatient services, and that nonphysician practitioners (PAs and advance practice nurses) may directly supervise cardiac and pulmonary rehabilitation services

SGR reform has come a long way, but hurdles remain. None of the committees that passed SGR legislation, for example, have included the cost offsets or “pay-fors” for enacting the reform. Once Congress returns in January, each body of Congress must determine the “pay-fors,” which will be considered on the House and Senate floors when each SGR package is debated and voted upon. After the House and Senate have passed SGR legislation, differences must be reconciled through a House-Senate conference committee.

AAPA has engaged the relevant congressional committees throughout the development of SGR proposals. Our overarching message has been straightforward: Treat PAs in the same manner as physicians and NPs, whether it relates to new benefits or new quality measures, and modernize Medicare to reduce unnecessary barriers to the quality medical care provided by PAs.

To date, all SGR proposals have embraced AAPA’s overarching message, and the Senate Finance Committee has addressed two federal barriers to care provided by PAs.

AAPA will continue to advocate for PAs in SGR repeal and reform, including retaining the PA hospice and critical access hospital provisions in the final legislation. Expect to hear from AAPA in the coming months as we ask you to add your voice to the continuation of this important public debate on Medicare payment reform.


Eighth Joint National Committee (JNC 8)

2014 Evidence-Based Guideline for the Management of High Blood Pressure in AdultsReport From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)



Hypertension is the most common condition seen in primary care and leads to myocardial infarction, stroke, renal failure, and death if not detected early and treated appropriately. Patients want to be assured that blood pressure (BP) treatment will reduce their disease burden, while clinicians want guidance on hypertension management using the best scientific evidence. This report takes a rigorous, evidence-based approach to recommend treatment thresholds, goals, and medications in the management of hypertension in adults. Evidence was drawn from randomized controlled trials, which represent the gold standard for determining efficacy and effectiveness. Evidence quality and recommendations were graded based on their effect on important outcomes.

There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90 mm Hg and hypertensive persons 30 through 59 years of age to a diastolic goal of less than 90 mm Hg; however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those younger than 30 years for a diastolic goal, so the panel recommends a BP of less than 140/90 mm Hg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults with diabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. There is moderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes. In the black hypertensive population, including those with diabetes, a calcium channel blocker or thiazide-type diuretic is recommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes.

Although this guideline provides evidence-based recommendations for the management of high BP and should meet the clinical needs of most patients, these recommendations are not a substitute for clinical judgment, and decisions about care must carefully consider and incorporate the clinical characteristics and circumstances of each individual patient.


Hypertension remains one of the most important preventable contributors to disease and death. Abundant evidence from randomized controlled trials (RCTs) has shown benefit of antihypertensive drug treatment in reducing important health outcomes in persons with hypertension.13 Clinical guidelines are at the intersection between research evidence and clinical actions that can improve patient outcomes. The Institute of Medicine Report Clinical Practice Guidelines We Can Trustoutlined a pathway to guideline development and is the approach that this panel aspired to in the creation of this report.4


The panel members appointed to the Eighth Joint National Committee (JNC 8) used rigorous evidence-based methods, developing Evidence Statements and recommendations for blood pressure (BP) treatment based on a systematic review of the literature to meet user needs, especially the needs of the primary care clinician. This report is an executive summary of the evidence and is designed to provide clear recommendations for all clinicians. Major differences from the previous JNC report are summarized in Table 1. The complete evidence summary and detailed description of the evidence review and methods are provided online (see Supplement).




Concussion in Sports

web-shutterstock 3017082The United States Bone and Joint Initiative (USBJI) works to advance the understanding and treatment of musculoskeletal conditions – bone and joint disorders – through research, prevention and education. It is the U.S. National Action Network of the worldwide Bone and Joint Decade, a multi-disciplinary initiative focused on improving bone and joint health, and quality of life for those afflicted with related disorders.

USBJI organizations are engaged in developing new research and education programs that will generate significant advances in the knowledge, diagnosis and treatment of musculoskeletal conditions, and increase the number of resources available to healthcare professionals and the public at large.

The goals of the Initiative are to:

• Raise awareness and educate the world on the increasing societal impact of musculoskeletal injuries and disorders.

• Empower patients to participate in decisions about their care and treatment.

• Increase global funding for prevention activities and treatment research.

• Continually seek and promote cost-effective prevention and treatment of musculoskeletal injuries and disorders.

The USBJI recognizes the unique needs of children as they grow and develop. The Initiative’s Pediatric Specialty Group focuses on identifying primary areas of concern with regard to the musculoskeletal health of children. The Pediatric Specialty Group develops programs and activities to increase awareness, provide education, and promote healthy living as a means of reducing the burden of disease. Priorities include healthy lifestyles; reducing infectious disease of the musculoskeletal system; trauma prevention; improving access to high quality, ongoing care for children with limb deficiencies; optimizing bone, joint and muscle function in children with chronic neuromuscular and musculoskeletal disorders; and successful transition from pediatric to adult care for childhood onset musculoskeletal disorders.

Specific subsets within these priorities are selected to receive universal attention and focus on World Pediatric Bone and Joint (PB&J) Day, annually observed on Oct. 19. The Pediatric Specialty Group instituted the first PB&J Day in 2012. This day occurs during Bone and Joint National Action Week, Oct. 12 – 20, a time of global awareness and education.

Injuries to the musculoskeletal system in children and adolescents, especially those involving trauma to the shoulder or neck often produce head injury in the form of a concussion along with the musculoskeletal trauma. Recognition of the co-morbid neurologic injury has critical

implications for musculoskeletal as well as overall recovery. The severity of neurologic symptoms as well as the sequelae of repeated trauma have far reaching implications for both the short term and long term recovery process. This can include exercise intolerance during the recovery process, impairment of activities of daily living, and impairment of musculoskeletal function as well. The following is a discussion of the common traumatic injury known as concussion; it is the hope that increased awareness of this condition as it relates to musculoskeletal trauma will only serve to aid the recovery of injured children and adolescents.

Description of Issue:

Concussion, a form of mild traumatic brain injury (TBI), is a common consequence of trauma to the head in contact sports. As many as 3.8 million sports-related concussions occur in the United States each year. While the majority of concussions are self-limited injuries, catastrophic results can occur and the long-term effects of multiple concussions are unknown. A history of prior concussion may increase the risk for recurrent concussions.1,2

The effect of concussion on developing brains is of particular concern. Children with concussion, particularly multiple concussions, are at high risk for developing headaches and suffering from impaired memory, cognitive function, attention, or other behavioral changes.1 Concussions occur in all sports with the highest incidence in football, hockey, rugby, soccer, and basketball.2


Concussion is defined as a traumatically induced transient disturbance of brain function and involves a complex pathophysiologic process. Concussion is a subset of mild TBI that is generally self-limited and at the less severe end of the brain injury spectrum.2

Risk Factors for Sports-Related Concussion:

• A history of concussion is associated with a higher risk of sustaining another concussion.2

• A greater number, severity, and duration of symptoms after concussion are predictors of a prolonged recovery.2

• In sports with similar playing rules, the reported incidence of concussion is higher in females than males.2

• Certain sports, positions, and individual playing styles have a greater risk of concussion.2

• Youth athletes may have a more prolonged recovery and are more susceptible to a concussion accompanied by a catastrophic injury.2

• Preinjury mood disorders, learning disorders, attention deficit disorders (ADD/ADHD), and migraine headaches complicate diagnosis and management of concussion.2

‘Sideline’ Evaluation and Management:

• Signs and symptoms of suspected concussion include: headache, dizziness, confusion, feeling like "in a fog", difficulty concentrating, difficulty remembering, "don’t feel right", balance

problems, amnesia, feeling slowed down, "pressure in head", sensitivity to light or noise, fatigue or low energy, drowsiness, more emotional, nervous or anxious, irritability, sadness, blurred vision, neck pain, nausea or vomiting, seizure or convulsion, or loss of consciousness.3

Any athlete suspected of having a concussion should be removed from play and assessed by a licensed healthcare provider trained in the evaluation and management of concussion.1,2,3

• Recognition and initial assessment of concussion should be guided by a symptom checklist, cognitive evaluation (including orientation, past and immediate memory, new learning, and concentration), balance tests, and further neurologic physical examination.2

Diagnosis of Concussion:

• Concussion remains a clinical diagnosis ideally made by a healthcare provider familiar with the athlete and knowledgeable in the recognition and evaluation of concussion.2

• Graded symptom checklists provide an objective tool for assessing a variety of symptoms related to concussions, while also tracking the severity of those symptoms over serial evaluations.2


• When premature cognitive or physical activity occurs before full recovery the brain may be vulnerable to prolonged dysfunction.2

• Students will require cognitive rest and may require academic accommodations such as reduced workload and extended time for tests while recovering from concussion.2

• Concussion symptoms should be resolved before returning to exercise.2

• A return-to-play progression involves a gradual, stepwise, increase in physical demands, sports-specific activities, and the risk for contact.2

• If symptoms occur with activity, the progression should be halted and restarted at the preceding symptom-free step.2

• Return to practice/ play after concussion should occur only with medical clearance from a licensed healthcare provider trained in the evaluation and management of concussion.1,2,3


• Greater efforts are needed to educate involved parties including athletes, parents, coaches, officials, school administrators, and healthcare providers to improve concussion recognition, management, and prevention.2 This education should include risk factors for concussion such as prior history of concussion, with the number, severity, and duration of symptoms noted as they known factors in concussion recovery.

• Primary prevention of some injuries may be possible with modification and enforcement of the rules and fair play.2

• Helmets, both hard (football, lacrosse, and hockey), and soft (soccer, rugby), are best suited to prevent impact injuries (fracture, bleeding, laceration, etc) but have not been shown to reduce the incidence and severity of concussions.2

References/ Resources:

1. American Academy of Neurology. Position Statement: Sports Concussion. Updated March 2013, Accessed June 30, 2013

2. Harmon K, American Medical Society for Sports Medicine Position Statement: Concussion in Sport. Clin J Sport Med. 2013;23(1):1-18

3. McCrory P, Consensus Statement on Concussion in Sport – the 4th International Conference on Concussion in Sport Held in Zurich, November 2012. Clin J Sport Med. 2013;23(2)89-117

Submitted by Bridget Burke

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