NP/PA supervision in provider-based departments

Happy holidays everyone! I thought I would write a bit about physician supervision. One of the clarifications that I have discussed with many people recently is related to nurse practitioners (NP) or physician assistants (PA). CMS clarified that NPs/PAs may not provide the physician supervision in provider-based departments. This fact was not a surprise to most, but the impact for NP/PA rendered services should be considered.

These extension providers often provide care in hospital-based clinics, such as urgent care centers or fast track facilities, without a physician being present in the department; in fact, they sometimes “cover” when the physician is unable to be present. However, the facility portion of this service is a hospital service subject to direct supervision under the hospital regulations.[1] Therefore, in accordance with the direct supervision guidelines discussed in the most recent OPPS final rule, a physician must be present in the department for the hospital facility service to be covered by Medicare.

Some confusion has arisen because these visits are generally appropriate under most state laws that allow NPs/PAs to practice without a physician on the premises. Additionally, the professional service by a NP/PA need not be under direct supervision for the service to be billable as a covered professional service to Medicare. The NP/PA would simply bill under his or her own NPI and be paid at a lower rate. Because the service is provided within the NP/PA’s scope of service (and is generally thought of as a professional service), many providers have not considered that the hospital direct supervision requirements apply to the facility portion—and that without a physician present, the hospital facility service is not covered.

I encourage providers to review the guidance on NPs/PAs in the OPPS final rule and evaluate locations where these extension providers might be providing services without a physician present some or all of the time.

[1] The regulations exempt rural health clinics and federally qualified health centers from the direct supervision requirements.