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CMS tears down walls for physician supervision

November 16, 2010

More physicians should be able to provide supervision for outpatient procedures after CMS finalized a change to its physician supervision requirements in the 2011 OPPS final rule, released November 2.

Beginning in 2011, “immediately available” will mean “physically present, interruptible, and able to furnish assistance and direction throughout the performance of the procedure but without reference to any particular physical boundary.” But CMS will no longer require physicians to be present in every off-campus provider-based department (PBD).

The meaning of the phrase “immediately available” will not change per se, says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., in Marblehead, MA. CMS clarified in the rule that it means physically present, interruptible, and able to furnish assistance and direction throughout the performance of the procedure. “The change is that the walls have come down and the same rules apply to on-campus and off-campus services,” she adds.

That change offers a lot of flexibility to hospitals, says Kathy Dorale, RHIA, CCS, CCS-P, vice president of HIM at Avera Health System in Sioux Falls, SD, and a member of the Provider Roundtable. Avera includes 28 hospitals, 24 of which are critical access hospitals (CAH).

“It honestly does help us by loosening those boundaries of what it means to be immediately available,” Dorale says. Now a physician can supervise a service from a location off the campus of the hospital, such as a clinic across the street. Avera and many midwest CAHs have that type of setup, so the change will help those hospitals, Dorale says.

Prior supervision requirements
CMS made several changes to its physician supervision requirements in the 2010 OPPS final rule. In it, CMS permitted non-physician practitioners (NPP) (e.g., physician assistants, nurse practitioners, clinical nurse specialists, certified nurse midwives, clinical social workers, and clinical psychologists) to provide direct supervision for hospital outpatient therapeutic services when their state license allows them to do so.

The prior definition required a physician or NPP to be in the department for off-campus PBDs, such as an off-campus wound care clinic. RNs with special training usually performed the wound care. Even though the RNs provided the treatment, a physician or NPP was required to be in the department even though they were not providing any treatment. They could be seeing other patients or doing paperwork, for example. But this was an additional cost for facilities to have this level of supervision by physicians not performing other services.

New supervision requirements

The change in the definition gives hospitals more leeway in scheduling physicians and NPPs for those off-campus departments, but, the physician or NPP responsible for providing supervision still needs to be immediately available. The physician or NPPS needs to know what services he or she is supervising, who is providing the service, and when that service is being performed.

Communication with the supervising practitioner at off-campus locations will be critical, says Mackaman. Facilities will need to put some type of organizational scheduling in place so that staff members don’t just assume a physician in another department is providing supervision. Schedulers will also have to look at what types of procedures are planned when a physician is responsible for providing supervision.

"They cannot be scheduled for a surgery that can’t be interrupted during the time the wound care is being provided or they cannot be so far off campus, for instance at the gym 10 miles away with the cell phone turned off, that they cannot respond ‘without lapse of time’,” Mackaman says.

Meeting the supervision requirements
CMS’ decision to back away from the boundary requirement provides hospitals with more options when they deliver services. However, the onus is still very much on hospitals because if audited by CMS, recovery audit contractors, or other payers, they will need to be able to prove who the supervisory physician was, how the physician was immediately available, and that he or she could in fact be interrupted.

Schedulers and HIM staff members have been looking at which, if any, physicians or NPPs were in the hospital, Dorale says. With CMS removing the words “in the hospital” from the supervision requirements, facility staff members will be able to look to see who is available in the clinic setting as well, Dorale says.

Each facility will have different criteria and different staffing situations, so no one-size-fits-all solution exists. When determining whether the facility is meeting the supervision requirements, Mackaman suggests considering these areas among others:

• Who is responsible and which days?
• What are the hours of operation?
• How will staff contact the supervising practitioner if he or she is not in the department? What is the expected response time?
• What are the limitations of where the supervising practitioner can go when he or she is responsible for supervision (e.g., must stay within five miles of the off-campus department)?

Physician supervision and CAHs
The changes CMS made to the supervision requirements will not eliminate the problems CAHs and small rural hospitals have with after-hours care. Many CAHs and small rural hospitals do not have physicians in the facility 24 hours a day. However, the supervision changes will not affect CAHs in calendar year 2011 because CMS will not evaluate or enforce the “direct supervision” requirement for therapeutic services furnished to outpatients in CAHs and rural hospitals next year. CMS initially suspended the requirement in March 2010 for CAHs only.

CAHs made compelling enough arguments that CMS needed to look at this area more carefully before requiring direct supervision. However, CMS continues to make the point that CAHs cannot operate just under their Conditions of Participation (CoP), but should be required to follow CMS’ physician supervision rules as well.

In addition to CAHs, in 2011 CMS is suspending requirements for small and rural hospitals with 100 beds or less that are paid under OPPS because they facesimilar staffing problems.

E-mail your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at mleppert@hcpro.com.