On July 20, 2009, CMS published a proposed rule regarding the Medicare Hospital Outpatient Prospective Payment System (HOPPS) for CY 2010. Among other items, the Proposed Rule addresses “long-standing” physician supervision requirements for hospital outpatient diagnostic and therapeutic services.
From 42 CFR 410.27(f) “Services furnished at a provider-based department of a hospital must be furnished under the “direct supervision” of a physician. “’Direct supervision’ means the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.”
Also from Section 20.5.1 of the Medicare Benefit Policy Manual, Effective January 1, 2009, CMS also revised Section 20.5.1 of the Medicare Benefit Policy Manual to specify that for services furnished at a provider-based department of a hospital, “direct supervision” means: the physician must be “present and on the premises of the location (the provider-based department of the hospital) and immediately available to furnish assistance and direction throughout the performance of the procedure”
This proposed rule provides definitions on on-campus, off-campus and provider-based outpatient therapy services. For CY 2010, CMS is proposing to allow non-physician practitioners (NPPs)—PAs, NPs, CNSs, CMWs—to directly supervise all hospital therapeutic services that they may perform themselves in accordance with their State law and scope of practice and hospital-granted privileges such as:
- Clinical psychologists may already provide and directly supervise hospital outpatient therapeutic services
- Direct supervision of cardiac rehabilitation (CR), intensive cardiac rehabilitation (ICR) and pulmonary rehabilitation (PR) services must still be furnished by a physician, as specified in the proposed coverage policies and regulations for said services
- Collaboration rules for these NPPs remain the same
According to compliance attorney Brian Annulis, Partner with Meade & Roache, LLP in Chicago, this rule would not apply to outpatient rehab services that are offered on the hospital campus and paid as part of the Medicare Physician Fee Schedule (MPFS), as well as those off-campus locations that have been deemed to have provider-based status that are also paid under the MPFS. It also does not apply to hospital outpatient rehab facilities that are certified as Rehab Agencies or Comprehensive Outpatient Rehabilitation Facilities (CORFs), also paid under the MPFS. In a recent audio conference on the new proposed rule, sponsored by Aegis Compliance & Ethics Center, Annulis commented that “the billing methodology is the key. If it is billed under Part B HOPPS then the rule applies. If billed under Part B MPFS then rule is not applicable.”