I 
108TH CONGRESS 
1ST SESSION H. R. 1388
To amend title XVIII of the Social Security Act to provide for coverage 
under the Medicare Program for surgical first assisting services of cer-
tified registered nurse first assistants. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 20, 2003
Mr. COLLINS introduced the following bill; which was referred to the Com-
mittee on Energy and Commerce, and in addition to the Committee on 
Ways and Means, for a period to be subsequently determined by the 
Speaker, in each case for consideration of such provisions as fall within 
the jurisdiction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to provide 
for coverage under the Medicare Program for surgical 
first assisting services of certified registered nurse first 
assistants.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Medicare Certified 
Registered Nurse First Assistant Direct Reimbursement 
Act of 2003’’.
SEC. 2. MEDICARE COVERAGE OF SURGICAL FIRST ASSIST-
ING SERVICES OF CERTIFIED REGISTERED 
NURSE FIRST ASSISTANTS. 
(a) SERVICES COVERED.—Section 1861(s)(2) of the 
Social Security Act (42 U.S.C. 1395x(s)(2)) is amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (U); 
(2) by inserting ‘‘and’’ at the end of subpara-
graph (V); and 
(3) by adding at the end the following new sub-
paragraph: 
‘‘(W) surgical first assisting services (as defined 
in subsection (ww)(1)) furnished by a certified reg-
istered nurse first assistant (as defined in subsection 
(ww)(2));’’. 
(b) SERVICES DESCRIBED.—Section 1861 of the So-
cial Security Act (42 U.S.C. 1395x) is amended by adding 
at the end the following new subsection: 
‘‘Surgical First Assisting Services; Certified Registered 
Nurse First Assistant 
‘‘(ww)(1) The term ‘surgical first assisting services’ 
means services consisting of first assisting a physician 
with surgery and related preoperative, intraoperative, and 
postoperative care (as determined by the Secretary) fur-
nished by a certified registered nurse first assistant (as 
defined in paragraph (2)) which the certified registered
nurse first assistant is legally authorized to perform by 
the State in which the services are performed. 
‘‘(2) The term ‘certified registered nurse first assist-
ant’ means an individual who—
‘‘(A) is a registered nurse and is licensed to 
practice nursing in the State in which the surgical 
first assisting services are performed; 
‘‘(B) has completed a minimum of 2,000 hours 
of first assisting a physician with surgery and re-
lated preoperative, intraoperative, and postoperative 
care; and 
‘‘(C) is certified as a registered nurse first as-
sistant by an organization recognized by the Sec-
retary.’’. 
(c) PAYMENT AMOUNT.—Section 1833(a)(1) of the 
Social Security Act (42 U.S.C. 1395l(a)(1)) is amended—
(1) by striking ‘‘and’’ before ‘‘(U)’’; and 
(2) by inserting before the semicolon at the end 
the following: ‘‘, and (V) with respect to surgical 
first assisting services (as defined in section 
1861(ww)(1)) furnished by a certified registered 
nurse 
first 
assistant 
(as 
defined 
in 
section 
1861(ww)(2)), the amount paid shall be 80 percent 
of the lesser of the actual charge for the services or 
85 percent of the amount determined under the fee
schedule established under section 1848(b) for the 
same services if furnished by a physician’’. 
(d) PAYMENTS TO EMPLOYERS.—
(1) IN GENERAL.—Section 1833(r) of the So-
cial Security Act (42 U.S.C. 1395l(r)) is amended—
(A) in paragraph (1), by inserting ‘‘or sec-
tion 1861(s)(2)(W) (relating to surgical first 
assisting services)’’ after ‘‘clinical nurse spe-
cialist services)’’; and 
(B) 
in 
paragraph 
(2), 
by 
striking 
‘‘1861(s)(2)(K)(ii)’’ 
and 
inserting 
‘‘1861(s)(2)(K)(ii) or 1861(s)(2)(W)’’. 
(2) APPLICATION OF MANDATORY ASSIGNMENT 
RULES.—Section 1842(b)(18)(C)(i) of such Act (42 
U.S.C. 1395u(b)(18)(C)(i)) is amended by striking 
‘‘physician assistant, nurse practitioner, clinical 
nurse specialist’’ and inserting ‘‘physician assistant, 
nurse practitioner, clinical nurse specialist, or cer-
tified registered nurse first assistant’’. 
(3) EXCLUSION
FROM
BUNDLED
PAYMENTS 
FOR COVERED SKILLED NURSING FACILITY SERV-
ICES.—Section 1888(e)(2)(A)(ii) of such Act (42 
U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting 
‘‘surgical first assisting services of a certified reg-
istered nurse first assistant,’’ after ‘‘services of a 
certified registered nurse anesthetist,’’. 
(e) REDUCTION IN PAYMENTS TO AVOID DUPLICATE 
PAYMENT.—Notwithstanding any other provision of law, 
the Secretary of Health and Human Services may reduce 
the amount of payments otherwise made to hospitals 
under title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.) to eliminate estimated duplicate payments 
for historical or current costs attributable to surgical first 
assisting services furnished by certified registered nurse 
first assistants as described in section 1861(ww) of such 
Act (as added by subsection (a)). 
(f) EFFECTIVE DATE.—The amendments made by 
this section shall apply to services furnished on or after 
the date of the enactment of this Act. 
SEC. 3. STUDY OF PAYMENT RATES. 
Not later than 180 days after the date of the enact-
ment of this Act, the Secretary of Health and Human 
Services shall submit to Congress a report containing rec-
ommendations for adjustments to the payment amounts 
established under part B of title XVIII of the Social Secu-
rity Act for surgical first assisting services furnished by 
certified registered nurse first assistants (as described in 
section 1861(ww) of such Act (as added by section 1(a)) 
to ensure that the payment amounts reflect the approxi-
mate costs of furnishing such services, taking into account 
the costs of compensation, overhead, and supervision at-
tributable to certified registered nurse first assistants.
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