April 09, 2012 | | Comments 1
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CMS clarifies regulations for outpatient rehabilitation and respiratory services

CMS  did not publish any major regulatory changes this week, which can be good news for providers who are so busy with other agenda items such as resolving 5010 conversion issues, addressing ICD-10 implementation delay concerns, and applying the various CMS incentive programs.

I will take this time to review a transmittal that came out several weeks ago about a topic that I learned  has been discussed in the provider community since last November. On March 23, CMS issued Transmittal 81 removing controversial language from Appendix A of the State Operations Manual for Hospitals. The Interpretive Guidelines and Survey Procedures language that was removed had stated that the ordering practitioner must have medical staff privileging to write the orders for rehabilitation and respiratory services. There had been concern in the provider community that this language limited the individuals that could order these services on an outpatient basis and thereby restrict the beneficiary’s access to them. The applicable regulations – §482.56(b) and §482.57(b)(3) – remain the same without further guidance.

During the February 22, Hospital Open Door Forum (ODF) call, CMS clarified that its May 2011 guidance was intended to expand the categories of practitioners who could order rehabilitation and respiratory care services to include nurse practitioners, physicians’ assistants, and clinical nurse specialists as long as the hospital grants “privileging” in a manner consistent with its policies and procedures. However, the way the language was written, it actually had the opposite effect and was interpreted by providers and surveyors to mean that the ordering physician had to be on the medical staff of the facility, which is not always the case for outpatient services.

During the ODF call, the CMS representative clarified that:

“outpatient services may be ordered by a practitioner who has medical staff privileges or alternatively may also be ordered by a practitioner who doesn’t have medical staff privileges but who is responsible for the care of the patients, licensed in or holds a license recognized by the jurisdiction where the practitioner sees the patient, is acting within his or her scope of practice under state law and is authorized by the hospital’s medical staff policy.”

For example, a patient is treated in one state and returns to the state where he lives with a referral for services ordered by the treating physician from the other state. CMS stated this was allowable as long as the written hospital policy addressed these types of scenarios and how the license of the ordering practitioner would be verified.

The Hospital State Operations Manual sections have not been updated as of yet; however, the language change was effective March 23.  You can also review the February 17 CMS Survey and Certification Letter for more discussion on this change.

Entry Information

Filed Under: OPPS


Debbie Mackaman About the Author:

Debbie is an instructor for HCPro’s Medicare Boot Camp®—Hospital Version. She has over 18 years of experience in the healthcare industry, including both inpatient and outpatient Prospective Payment Systems (IPPS, OPPS) and Critical Access Hospital (CAH) coding and reimbursement issues. She most recently held the position of the Compliance Officer and Director of Health Information Services for a healthcare system.

She consults with hospitals, physicians and other healthcare providers on a wide range of coding and billing issues. She assists in the development of compliance programs, with a focus on high risk areas including RAC topics, documentation improvement, coding and billing audits, and chargemaster maintenance.

She is an active participant with state and national organizations and task forces on coding and payment policies, privacy and continuing education. She is accredited as a Registered Health Information Administrator (RHIA) and a Certified Healthcare Compliance Officer (CHCO). She is a member of the American Health Information Management Association (AHIMA) and is the past president of the Montana Health Information Management Association (MHIMA).

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  1. Debbie, I attended your Boot Camp and saw this that reminded me of an issue I am trying to get clairified. Our Rehab Manager is trying to clairfy rules for Rehab. She wants to understand the requirements for Cardiac Rahab and thinks in terms of three phases of rehab. This does not relate to the New category of Intensive CR.

    She thinks for Phase III of CR they may be able to provide the service wihtout direct supervision and i say no. Medicare does not recognize differences in pahses of CR and has only one type of supervision for CR which is as follows: Effective January 1, 2011, hospitals may change to general supervision for a portion of services defined as non-surgical extended duration therapeutic services (“extended duration services”) but only as specified in this manual for those services (see section 20.7). Pulmonary rehabilitation, cardiac rehabilitation, and intensive cardiac rehabilitation services require direct supervision which must be furnished by a doctor of medicine or osteopathy, as specified at 42 CFR 410.47 and 410.49, respectively.

    Can you clarify for us?

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