Proposed OPPS revises physician supervision
Proposed OPPS revises physician supervision
The Centers for Medicare & Medicaid Services (CMS) once again has changed the requirements for physician supervision, always an area of contention and confusion, in its proposed 2011 outpatient prospective payment system (OPPS) rule.
In response to comments from critical access hospitals last year about a conflict on the topic between the Conditions of Participation (CoPs) and EMTALA, CMS first said critical access hospitals (CAHs) would not have to follow the final rule's requirements for physician supervision. After evaluation, however, CMS decided not to exclude CAHs from meeting the supervision requirements.
"The proposed rule addresses the disconnect between the CoPs and the supervision rule under the more general provider-based rule. The CoPs only require that CAHs have a nurse on the premises (with a physician/practitioner on call) when there are patients in the hospital. Because observation services are therapeutic (at least theoretically), the physician supervision rule would require that a physician be on the campus," says Duane Abbey, PhD, CFP, president, Abbey & Abbey Consultants Inc.
In general, says Adrienne Dresevic, of The Health Law Partners PC, "for on-campus services, direct supervision means the supervising physician or non-physician needs to be present on the campus of the hospital or CAH and immediately available to provide assistance. For off-campus remote locations, the supervising physician or non-physician needs to be present in the off-campus location."
Those services that CMS has defined as nonsurgical extended-duration therapeutic services "will require direct supervision during an initiation period, followed by a minimum standard of general supervision for the duration of the service. Thus, the services are not exempt from supervision but after the initiation period are subject to a lower level of supervision," she says.
Such services had to meet four criteria:
- must be of extended duration, frequently extending beyond normal business hours;
- not a surgical service;
- consist of a significant monitoring component, which is typically conducted by nursing or other auxiliary staff;
- are low risk, such that it would not require direct supervision often during the performance of the procedure. (See below, for list of services.)
Proposed list of nonsurgical extended duration therapeutic services includes: intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring use of portable or implantable pump; hospital observation service, per hour; direct admission of patient for hospital observation care; intravenous infusion, hydration; initial, 31 minutes to 1 hour; intravenous infusion, hydration; each additional hour (list separately in addition to code for primary procedure); intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour; intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure); intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure); intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure); |
subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s); subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure); subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure); therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular; therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug; therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure); therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure).
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"CMS explicitly did not include chemotherapy or blood transfusions in the proposed list because it believes these services require the physician or non-physician practitioner's recurrent physical presence in order to evaluate the patient's condition in the event it is necessary to redirect the service," says Dresevic.
The supervising physician or non-physician practitioner must deem when the patient is "stable" and the service can continue under general direction "without their physical presence on the hospital campus or in the provider-based department of the hospital. CMS provides that the determination of when to move from direct to general supervision is up to the discretion of the supervising physician or non-physician practitioner. Thus, it is left to interpretation (but it should be the supervising physician's interpretation). CMS is considering whether the point of transfer from direct to general should be documented in the medical record or identified in a hospital protocol," says Dresevic.
How should hospitals document this to comply with supervision requirements? Abbey says: "This is probably the biggest overall compliance issue. Hospitals, both CAHs and short-term acute care hospitals, will need to set up documentation systems that show exactly what physician or practitioner was available to meet any given aspect of the supervision requirements."
Dresevic suggests using sign-in sheets or time logs to document physician presence on campus "during an at-issue time period. Time sheets and logs can also be incorporated into various physician contracts."
The Centers for Medicare & Medicaid Services (CMS) once again has changed the requirements for physician supervision, always an area of contention and confusion, in its proposed 2011 outpatient prospective payment system (OPPS) rule.Subscribe Now for Access
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