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CMS Answers Q&A Regarding Physician Supervision
June 2010
On April 23, 2010, CMS answered common questions about physician supervision
requirements. The article from the CMS website is printed below.
Common Questions about Supervision Requirements for Medicare Payment of Hospital
Outpatient Services
(1) Does Medicare require direct supervision for all services provided to
outpatients in hospitals?
CMS has identified supervision requirements for the provision of both
therapeutic and diagnostic services furnished to hospital outpatients. Medicare
requires hospitals to provide direct supervision for the delivery of all
outpatient therapeutic services. Direct supervision means that the
physician or non-physician practitioner is immediately available to furnish
assistance and direction throughout the performance of the procedure, but it
does not mean that the supervising individual needs to be present in the room
when the procedure is performed.
For diagnostic services provided to hospital outpatients, Medicare
requires hospitals to follow the existing supervision requirements in the
Medicare Physician Fee Schedule (MPFS) Relative Value File for individual
tests. The MPFS has three definitions of supervision - general, direct, and
personal. General supervision means that the procedure is furnished under the
physician’s overall direction and control, but the physician’s presence is not
required during the performance of the procedure. Personal supervision means a
physician must be in attendance in the same room during the performance of the
procedure.
For services provided by critical access hospitals (CAHs), CMS has directed its
contractors not to enforce the requirement for direct supervision of outpatient
therapeutic services during calendar year (CY) 2010 (please see notice at
http://www.cms.hhs.gov/HospitalOutpatientPPS/Downloads/WebNotice.pdf).
CMS will revisit the rule for supervision of services in CAHs in the CY 2011
rulemaking process for the hospital outpatient prospective payment system
(OPPS). CMS has only identified supervision requirements for the provision of
therapeutic services to outpatients in CAHs. At this time, there is no
requirement for specific levels of supervision for the provision of diagnostic
services in a CAH.
(2) Why are observation services considered therapeutic and subject to direct
supervision?
In Chapter 6 of the Medicare Benefit Policy Manual, section 20.6, we note that
observation care is commonly ordered for patients that present to the emergency
department, and that observation care is a well-defined set of specific,
clinically appropriate services which include ongoing short-term treatment,
assessment, and reassessment before a decision can be made regarding whether a
patient will require further treatment as a hospital inpatient. A patient
receiving observation services presents with complex, evolving conditions that
require active medical treatment and monitoring toward a decision to admit as
an inpatient or discharge the patient. While we recognize that some emergent
conditions progress more rapidly than others, we believe that the evolving
nature of observation services and the unknown nature of the individual’s
condition necessitate supervision. As indicated in section 20.6, in the
majority of cases, physicians can make this decision within 48 hours, and the
decision is usually made in less than 24 hours. We would not expect patients to
spend extended periods of time receiving observation services.
As indicated in section 20.5.2 of Chapter 6 of the Medicare Benefit Policy
Manual, outpatient therapeutic services and supplies are those furnished as
incident to the services of physicians and practitioners in the treatment of
patients. Such services include clinic and emergency room services, and are
furnished as an integral, although incidental, part of the physician or
non-physician practitioner's professional service in the course of treatment of
an illness or injury. Observation services include treatment comparable to an
emergency department or clinic visit. Accordingly, observation services are
therapeutic services. Patients receiving observation services may also receive
a variety of additional diagnostic tests.
(3) Does a physician or non-physician practitioner need to be immediately
available and on campus 24 hours a day, 7 days a week in order to meet
Medicare’s direct supervision requirements for payment purposes?
No, a physician or non-physician practitioner must provide direct supervision
only when therapeutic services are being furnished to Medicare outpatients. The
duration of many outpatient services is less than 24 hours, and, therefore,
most services would not require 24 hours per day, 7 days per week direct
supervision. Although many hospitals are continuously providing outpatient
services, some small hospitals may not always be treating hospital outpatients.
In these circumstances, we do not require hospitals to retain individual
physicians or non-physician practitioners waiting on the campus of the hospital
to supervise the therapeutic services that might be provided should a patient
appear. With regard to observation services, as noted above, these are
therapeutic services which must be provided under direct supervision; and we
expect the treating physician or non-physician practitioner to make a decision
to admit as an inpatient or discharge the patient as quickly as
possible—usually less than 24 hours.
(4) Is a physician or non-physician practitioner considered immediately available
as long as they are on the hospital campus?
Section 42 CFR 410.27(f) sets up a two-pronged requirement for direct
supervision of therapeutic services in the hospital or CAH: the physician or
non-physician practitioner must be present on the same campus of the hospital
and must be immediately available, meaning physically present. For the purposes
of supervision of hospital outpatient therapeutic services, we recognize the
413.65(a)(2) definition of campus as “the physical area immediately adjacent to
the provider's main buildings, other areas and structures that are not strictly
contiguous to the main buildings but are located within 250 yards of the main
buildings, and any other areas determined on an individual basis, by the CMS
regional office, to be part of the provider's campus." For payment purposes
specifically, we recognize other areas or structures of the hospital's campus
that are not part of the hospital, such as physician offices, rural health
centers, skilled nursing facilities, or other entities that participate
separately under Medicare to be part of the hospital’s campus.
In the CY 2010 OPPS final rule with comment period we noted that some hospital
campuses span several city blocks, and that the immediate availability
requirement would limit the distance a supervisory physician or non-physician
practitioner could be from the location where outpatient therapeutic services
are being furnished. On small campuses, a supervising physician or
non-physician practitioner typically could be anywhere on the hospital campus
and still meet the immediate availability requirement, provided that any
services he or she is furnishing could reasonably be interrupted. However, that
may not be the case for larger campuses.
(5) Can an emergency department physician or non-physician practitioner directly
supervise therapeutic outpatient services while in the emergency
department?
In most cases, the emergency physician or non-physician practitioner can
directly supervise outpatient services so long as the emergency physician in
the emergency department of the campus is immediately available, meaning that,
if needed, he or she could reasonably be interrupted to furnish assistance and
direction in the delivery of therapeutic services provided elsewhere in the
hospital. We have stated that the supervisor must be a person who is
“clinically appropriate” to supervise the therapeutic service or procedure. We
believe that most emergency physicians can appropriately supervise many
services within the scope of their knowledge, skills, licensure, and hospital
granted privileges including observation services. With regard to whether an
emergency physician or a non-physician practitioner could be interrupted, such
that the emergency physician could be immediately available, each hospital will
need to assess the level of activity in their emergency department and
determine whether at least one emergency physician or non-physician
practitioner could be interrupted to furnish assistance and direction in the
treatment of outpatients.
(6) Does a physician need to directly supervise therapeutic services delivered to
hospital outpatients or can other non-physician practitioners directly
supervise as well?
Beginning in CY 2010, non-physician practitioners, including nurse
practitioners, physician assistants, clinical nurse specialists, certified
nurse-midwives, and licensed clinical social workers may directly supervise the
provision of all hospital therapeutic services that that they may perform
themselves within their state scope of practice and hospital-granted
privileges, provided that they continue to meet all the requirements for
directly providing services, including any collaboration or supervision
requirements. Clinical psychologists were already permitted to directly
supervise hospital services provided to an outpatient, so long as those
services are within the psychologist’s state scope of practice and hospital
granted privileges.
(7) How will the requirement for direct physician supervision of therapeutic
services delivered to outpatients affect the review of claims by
contractors?
Neither supervision nor observation services are included on the Medicare
Recovery Audit Contractor (RAC) list of issues for CY 2010. The focus of each
year’s RAC review is identified by both contractors and CMS staff and approved
by CMS. CMS will ensure that the RACs, understand that an assessment of
supervision will require knowledge of the level of activity in a hospital at
any point in time and the hospital’s staffing structure and protocols before
approving any RAC audit. We will the inform MAC staff of these issues.
Only in the case of CAHs has CMS directed its contractors not to enforce the
requirement for direct supervision of outpatient therapeutic services that are
furnished during calendar year (CY) 2010. CMS continues to expect CAHs to
fulfill all other Medicare program requirements when providing services to
Medicare beneficiaries and when billing Medicare for those services.
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