Clinical Nurse Specialists (CNSs) are the second largest group of advanced practice registered nurses (APRNs) in the United States, accounting for approximately 20% of all APRNs. Nurse practitioners (NPs) account for approximately 69%, nurse anesthetists (CRNAs) for 9% and certified nurse midwives (CNMs) for 2%.
Even after 60+ years of providing safe, evidence-based, quality care, the versatility of the CNS role still remains one of the most underrecognized and underutilized in our healthcare systems. With almost 90,000 CNSs currently practicing in the U.S., why do only approximately 10,000 have a National Provider Identifier (NPI)?
What is the National Provider Identifier?
In 1996, the Health Insurance Portability and Accountability Act (HIPAA) mandated that all healthcare providers use a unique 10-digit identification number in all administrative and financial transactions. This number is called the National Provider Identifier (NPI). The Centers for Medicare and Medicaid Services (CMS) developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers to providers.
In 1997, Congress passed the Balanced Budget Act, recognizing the unique role of the CNS in our healthcare system and enabling CNSs to directly bill for services through CMS Part B participation in Medicare. At this time, approximately only 11% of CNSs have an NPI number, which implies that we are rarely, if ever, billing for our services.
Why Is Having an NPI Number Important?
The multifaceted CNS not only provides expert direct clinical care to patients but works to advance nursing practice through evidence and research. We demonstrate the value of nursing practice at the system level as an influencer of change — facilitating quality, cost-effective patient outcomes while advocating for the profession of nursing. While the CNS is truly comfortable from the bedside to the boardroom, the majority of us lack the national recognition that an NPI number provides.
In his research article for Medicare and Medicaid, Andrew B. Bindman, University of California, San Francisco and U.S. Department of Health and Human Services, notes, “The lack of an accurate, comprehensive health care workforce database may undermine the ability to monitor policies designed to improve access to care and to intervene when necessary to address barriers to care.”
The U.S. Bureau of Labor Statistics’ (BLS) Occupational Employment and Wage Statistics (OEWS) categorizes occupation profiles, including registered nurses, based on factors including the NPI number. Currently, CRNAs,CNMs and NPs are identified as unique groups with codes specific to their profession. CNSs are not.
- 29-1150 CRNAs
- 29-1160 CNMs
- 29-1170 NPs
One reason other APRN roles are well represented may be that hiring organizations proactively obtain NPI and DEA numbers and other regulatory items for them as part of the onboarding process, based on these roles’ recognized scope of practice. By doing so, a larger percentage of each role is acknowledged in the NPPES system, leading to unique group codes specific to the CRNA, CNM and NP.
At this time, the CNS is counted under the “Registered Nurse” category (29-1140) and is not identified as a separate advanced practice role. Hopefully, this may change as more states update legislature to grant CNSs full practice authority with prescriptive privileges.
The registered nurse description reads:
Assess patient health problems and needs, develop and implement nursing care plans, and maintain medical records. Administer nursing care to ill, injured, convalescent or disabled patients. May advise patients on health maintenance and disease prevention or provide case management. Licensing or registration required. Includes Clinical Nurse Specialists. Excludes “Nurse Anesthetists'' (29-1151), “Nurse Midwives” (29-1161), and “Nurse Practitioners” (29-1171).
This description does not recognize the CNS role as an advanced practice role or cover our competencies in the nursing or systems spheres of impact.
How Does NPI Underrepresentation Impact Our Profession?
Embedding the CNS role in the registered nurse category has several consequences for our profession:
- Hides CNS contributions to our healthcare system
- Prevents us from leveraging the number of practicing CNSs to support creation of much- needed updating of state rules and regulations governing nursing practice
- Inhibits our APRN recognition, title protection, independent practice and scope of practice efforts nationwide
- Limits government and philanthropic support for student scholarships to aid in expanding the CNS workforce
- Prevents tracking of CNS practice trends
The lack of billing for CNS services rendered also minimizes our ability to demonstrate the productivity of the CNS role in an organization or system.
In a peer-reviewed article supporting NPIs for CNSs, Sean M. Reed, PhD, APN, ACNS-BC, ACHPN, College of Nursing, University of Colorado, Aurora, asserts that “registering for the U.S. Census allows individual people to be recognized officially; registering in sufficient numbers builds political strength for their community.”
Echoing Reed’s statement, every CNS needs to be counted if full scope of practice with prescriptive authority in every state is to become a reality. We need to ensure that every practicing CNS is represented in the BLS OEWS and NPPES and in local, state and national organizations. NPI numbers are available to all CNSs, regardless of position title or the current state of CNS recognition in their state.
I am inspired by Reed’s remark, “Imagine for a moment if every CNS obtained an NPI.” Having more of a voice as CNSs means more than just having our unique BLS OEWS profession code; it would enable us to make a bigger impact, whether in the patient, nurse or systems sphere. A bolder voice would help us make changes at all system levels — hospital, state and federal. More importantly, making these changes so we can practice to the full scope of our education, training and experience would benefit patients by making safe, affordable care more available. Having recognized prescriptive authority would help us fill a much-needed gap in access to care for patients. What CNS doesn’t want this for themselves or their patients?
Where Do I Apply for an NPI Number?
Applying for an NPI number is easy and doesn’t take much time.
- If you have never created a CMS username/password, go to the Identity & Access Management System (I&A) and create your account.
- Log in to the National Plan and Provider Enumeration System (NPPES) website using your I&A username/password.
- Enter your demographic information, social security number and relevant healthcare provider and practice information.
- Select the healthcare provider taxonomy code “364S00000X” for CNSs.
- Select your specialty area, if appropriate. Note: Avoid the use of APN or APRN in the free-text credentialing field – it will not classify you according to your specific APRN role.
- Each year, check your information in NPPES for accuracy, and update as necessary.
How Else Can I Help?
Here are ways we can empower CNSs to obtain an NPI number:
- Encourage nursing schools to assist graduating students in obtaining an NPI number. Providing them with this information helps ensure every new CNS is counted.
- Ask our state boards of nursing to include NPI information when notifying CNSs that their recognition or license has been processed and approved.
- Engage our national and state nursing organizations to promote NPI numbers and provide members with information on how to complete the process.
- Urge co-workers to obtain an NPI number. Send out links, create a PowerPoint to walk your co-workers through the process step-by-step, or hold “office hours” for co-workers to stop by for help.
- Ensure we review our NPPES profile annually. Update our profile as needed to provide the most accurate information.
- Speak up. A recent article by Mitzi Saunders, PhD, APRN, CNS-C, University of Detroit Mercy, notes, “CNSs are invisible champions whose role is often misunderstood and underutilized.” Advocacy is one of the main components of our role. We all succeed when we advocate for our patients; however, when it comes to advocating for ourselves, we forget to use our voice. We need to be counted as APRNs and as CNSs.
CNSs have demonstrated throughout the pandemic that we are needed more than ever. It is time that we stop being the invisible APRN role in the healthcare system. We need to be able to practice to the full scope of our license to serve our patients, advocate for nurses and ourselves, and bring cost savings to our healthcare systems through evidence-based practices. But to be seen in today’s healthcare world we need to be counted — we need to obtain our NPI number.
So, are YOU ready to be counted?