All Entries Tagged With: "Physician supervision"
CMS issues 2010 final rule for ambulatory surgery centers and most hospital outpatient departments
CMS has released a display copy of the outpatient prospective payment system (OPPS) final rule for 2010, which also includes the 2010 changes to the rules for ambulatory surgery centers (ASCs). This final rule will be published in the Federal Register on November 20. In terms of reimbursement, OPPS hospitals that meet quality indicator reporting requirements for 2010 are entitled to the “full update,” which will result in a 2.1% increase in their payments for 2010. Those OPPS hospitals that do not meet their quality indicator reporting requirements will be subject to a reduced update of 0.1% in 2010. ASCs, on the other hand, will receive a 1.2% inflation update beginning January 1, 2010.
Among the most anticipated changes in the OPPS final rule are the so-called “incident to” a physician’s services requirements. Most nonphysician outpatient therapeutic services that are provided by hospitals or critical access hospitals (CAHs) are only covered if they are provided “incident to” the services of a physician or another specified nonphysician practitioner.
During the last few years, CMS has made several changes to the “incident to” rules. Prior to 2009, for example, such services had to be provided on the order of a physician. In 2009, CMS expanded the practitioners qualified to meet the order requirement to include clinical psychologists, licensed clinical social workers, physician assistants, nurse practitioners, clinical nurse specialists and certified nurse-midwives (the “NPPs”). In that same year, however, CMS clarified that, in order to be covered, such services must be provided under the supervision of a physician or clinical psychologist who is “on the premises” and immediately available. On the premises was defined as “present in the provider-based department.”
The latter revision prompted considerable response from the hospital community, which ultimately resulted in the following changes to the therapeutic “incident to” rules. These changes were announced in the OPPS 2010 final rule and will become effective for services provided on and after January 1, 2010.
In order to be covered, most therapeutic outpatient hospital and CAH services furnished incident to a physician or nonphysician practitioner must be furnished
- By or under arrangements made by the hospital or CAH;
- On the order of a physician or one of the specified NPPs;
- As an integral though incidental part of a physician’s or nonphysician practitioner’s services;
- In the hospital or CAH or in a provider-based department of the hospital or CAH; and
- Under the direct supervision of a physician or one of the specified NPPs (which includes the same nonphysician practitioners as those permitted to order such services); nonphysician practitioners may directly supervise services they are permitted to provide themselves within the scope of their licensure and hospital-granted privileges, assuming they otherwise meet all Medicare conditions of participation and related requirements.
In general, for services furnished in the hospital or CAH or in an on-campus provider-based department of the hospital or CAH, “direct supervision” means that the physician or nonphysician practitioner must be present on the same campus and must be immediately available to furnish assistance and direction throughout the procedure. It does not mean that he or she must be present in the room where the procedure is performed. “In the hospital or CAH” means areas in the main buildings of the hospital or CAH that are under the ownership, financial and administrative control of the hospital or CAH; that are operated as part of the hospital or CAH; and for which the hospital or CAH bills the services furnished under the hospital’s or CAH’s CMS Certification Number.
For services furnished in an off-campus provider-based department of the hospital or CAH, “direct supervision” means the physician or nonphysician practitioner must be present in the off-campus provider-based department and must be immediately available to furnish assistance and direction throughout the procedure. It does not mean that he or she must be present in the room where the procedure is performed.
Please note, however, there is an exception for pulmonary rehabilitation, cardiac rehabilitation and intensive rehabilitation services, wherever these services are provided. For these services, direct supervision must be furnished by a doctor of medicine or osteopathy, whether provided in the hospital or CAH or in an on- or off-campus provider-based department of the hospital or CAH.
Please also note that these most recent revisions do not become effective until January 1, 2010. Prior existing rules will be effective through December 31, 2009. Hospitals and CAHs are advised to review these updated “incident-to” rules, and to make such modifications to existing policies and procedures as necessary to assure that they are in compliance with these changes, effective for dates of service on and after January 1, 2010.
Recent OIG Reports and Medical Review Implications
In last week’s post, we looked at the OIG Work Plan for Fiscal Year 2010. There were many issues listed for both Part A and Part B that will be on the radar for a targeted review. Hospitals are encouraged to closely examine the OIG Work Plan as part of their annual compliance program review process.
In addition, reviewing OIG audits can help hospitals and physicians identify some challenging areas within their own operations. This week, CMS published Transmittal 574 that focused on four recent OIG reports:
- Part B Chemotherapy Administration Payment and Policy;
- Prevalence and Qualifications of Nonphysicians Who Perform Medicare Physician Services;
- Inappropriate Medicare Payments for Chiropractic Services; and,
- Part B Billing for Ultrasound.
In these reports, the OIG presented their findings and made recommendations for CMS to reduce the Medicare program’s vulnerability with regards to questionable claims. This transmittal directs all contractors – Carriers, Fiscal Intermediaries (FI), and Medicare Administrative Contractors (MAC) – to review the information contained in the OIG reports and begin to analyze claims data for these areas. If the contractor’s findings indicate potential problems with their providers and suppliers, they have been directed to take the appropriate action, which may include automated prepayment edits and/or pre- and post-payment reviews.
Hospitals should review this transmittal and the related OIG reports to identify any issues that may need to be addressed as soon as possible. Staying abreast of the OIG audit reports is necessary in today’s regulatory environment. These reports can help guide a facility’s compliance activities, help identify processes that may need correction and prevent recoupments in the future.
2010 OPPS proposed rule released
This was a busy week, but the biggest news was the somewhat early release of the OPPS proposed rule for 2010. While the rule is about the same number of pages as previous years, the substantive policy changes seem fewer than in the last couple of years.
For instance there were no new composite APCs introduced this year. Additional composite APCs, including cardiac resynchronization therapy, are being considered for future years. However, CMS indicated that in accordance with comments received in response to the previous composite APCs, they were going to study the effects of existing composites on payment and utilization before introducing additional composite APCs.
One of the more important proposals in the rule relates to physician supervision, a topic we have discussed several times. CMS discusses the recent “restatements” and “clarifications” made over the course of the last year and proposes regulatory changes in accordance with some of the comments they have received from many industry groups.
OPPS, MPFS, NCCI developments
You may have heard about two big announcements yesterday from CMS:
We’re still analyzing these changes, but a look at the CMS fact sheet on the OPPS issuance shows some proposals related to the controversial physician supervision issue:
Physician supervision requirements – CMS is proposing to revise or further define several current policies for the physician supervision of outpatient services. First, CMS is proposing that nonphysician practitioners, specifically physician assistants, nurse practitioners, certified nurse specialists, and certified nurse-midwives, may directly supervise all hospital outpatient therapeutic services that they are able to personally perform within their state scope of practice and hospital-granted privileges. Under current policy, only physicians may provide the direct supervision of these services.
In addition, CMS is proposing to define “direct supervision” for on-campus hospital outpatient services to mean that the physician or nonphysician practitioner must be present in the hospital or on-campus provider-based department of the hospital and immediately available to furnish assistance and direction throughout the performance of the procedure, in contrast to the current definition which requires the physician to be present in the on-campus provider-based department. For services furnished in an off-campus provider-based department, “direct supervision” would continue to mean that the physician or nonphysician practitioner must be present in the off-campus provider-based department and immediately available to furnish assistance and direction throughout the performance of the procedure.
Yesterday also brought a change in NCCI edits for the new quarter. Check these out using our special NCCI lookup tool, available to subscribers or free-trial users.
Purchase MedicareFind to start FINDing late-breaking developments like these. You can also try a free trial to test drive the site.
Observation with condition code 44 and physician supervision
Last week, the American Health Lawyers Association held their annual Institute on Medicare and Medicaid Payment Issues in Baltimore. After speaking about observation at a conference session, I had the opportunity to speak to a CMS representative informally about condition code 44 as it relates to observation and also about physician supervision in hospital outpatient departments. [more]
Listen to the February 25 Hospital Open Door Forum
CMS held its latest conference call for hospitals on February 25. This call featured an extensive discussion of “incident to.” If you’re new to this issue, check out the discussion here.
You can listen to the audio below. Subscribers to the MedicareFind database also have access to a transcript of the call.
What is your reaction to CMS’ recent activity regarding “incident to” coverage requirements?
Try a free trial to MedicareFind and gain access to transcripts and audio of CMS’ Hospital Open Door Forum calls.
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. [more]
