Health Law MonitorCMS recently released its 2010 Outpatient Prospective Payment System (“OPPS”) rule clarifying the requirements for supervision of certain hospital outpatient services. The rule makes clear that if direct physician supervision is required for the performance of an outpatient service, this level of supervision may not be assumed to exist in a hospital setting. Rather, a hospital must establish a plan or policy to ensure that the direct supervision required by the Centers for Medicare and Medicaid Services (“CMS”) for a particular outpatient service is available. Read More.
On October 30, 2009, the CMS released its 2010 OPPS rule updating Medicare payment policies and rates for hospital outpatient departments. The rule includes three notable clarifications for outpatient services that require “direct supervision,” including outpatient therapeutic services furnished as “incident to” physician’s services.
First, certain non-physician practitioners (“NPPs”) including physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives, clinical psychologists, and licensed social workers will be permitted to provide direct supervision for hospital outpatient therapeutic services that they are authorized to personally perform both according the scope of practice rules under applicable state law and according to their hospital-granted privileges. Previously, only physicians were permitted to directly supervise outpatient hospital services. The use of NPPs to supervise applies only to hospital outpatient therapeutic (but not diagnostic) services, and specifically does not apply to cardiac rehabilitation, intensive cardiac rehabilitation, or pulmonary rehabilitation.
Second, for on-campus outpatient therapeutic services, the direct supervision requirement will be met if a physician or NPP is present on the campus and is immediately available to assist throughout the performance of the procedure. It does not require the physician or NPP to be present in the actual room, or necessarily in the same department, when the procedure is performed. Instead, the physician or NPP must be on the campus and “immediately available.” CMS did not define “immediately available,” but indicated in the preamble to the rule that “immediate” means “without interval of time.” In the case of an off-campus provider based department (“PBD”), the rule requires the physician or NPP to be physically present in the off-campus PBD in order to satisfy the direct supervision requirement.
Third, all hospital outpatient diagnostic services, regardless of location, must be provided with the same level of physician supervision that is required for the specific service under the Medicare Physician Fee Schedule (“MPFS”). These levels of physician supervision could be general, direct, or personal. NPP supervision is not sufficient. If the level required is direct supervision, the physician will have to be present on the hospital campus and immediately available to assist. In the case of an off-campus PBD, such as a freestanding imaging center, a direct supervision requirement would mandate that the physician be physically present in the off-campus PBD at the time the procedure in performed.
Hospitals must review their policies to ensure that their supervision standards meet the new requirements of the 2010 OPPS rule. Policies and procedures should clearly define specific physicians and/or NPPs who are responsible for supervision at any given time, and how they should be summoned when needed. In addition, non-physician personnel in the hospital will need to know who is the supervising physician or NPP at any given time. To comply, hospitals need to carefully evaluate the availability of all their professional staff resources (ER physicians, hospitalists, other medical staff members, NPPs, etc.) during all hours that affected outpatient procedures are being performed.
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