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Outpatient Services and the New CMS Regulations

October 10th, 2016

CMS recently published a survey and certification memo containing the final interpretive guidelines for hospital outpatient services.

These guidelines were based on the federal regulations that went into effect last July. The medical staff and board can decide who is eligible to order outpatient tests. Hospitals can decide what can be ordered by physicians and other practitioners who are both privileged and which tests can be ordered by those who are not.

HPR for Hospital Consult

An order is required for any outpatient test or procedure. The language now reads that an order is needed by a practitioner who is responsible for the care of the patient who is licensed in the state where he or she provides care to the patient. For example, an Ohio patient spends the winters in Florida and has a prescription to have outpatient lab tests such as an INR because the patient is on warfarin (Coumadin). The Florida hospital can decide if they will honor the prescription and perform the lab test for the patient.

The hospital could accept orders of other practitioners as allowed within their state scope of practice. This must be authorized by the medical staff and approved by the board. Many states allow other practitioners, such as Nurse Practitioners (NP) and Physician Assistants (PA) to order a test or procedure. The state board of nursing usually sets forth the scope of practice for a NP and this information is generally contained on their website. Likewise, the state medical board generally sets forth the scope of practice for the PA and lists this on their website. This makes it easier for hospitals to verify the scope of practice for practitioners from other states when they decide to honor these orders. License can be verified online also. Hospital should consider what else should be verified such as if the person is on the Office of Inspector General’s (OIG) list of excluded individuals.

The list of excluded individuals can be searched here. The order should also be consistent with any state law requirements.

These changes affect tag number 1076, 1080, and 1081. The CMS manual will be amended to reflect these changes. The current CMS manual is available here.

Hospitals should review these three revised tag numbers and have a list of what orders can be accepted in the outpatient area. This includes practitioners with privileges and those who do not. The hospital should have a clear policy of what staff should do, such as the outpatient registration personnel and outpatient staff when they receive an outpatient orders. There should be documentation of the verification process. Outpatient orders could include things like lab tests, physical therapy, occupational therapy, speech pathology services, rehabilitation, blood, outpatient chemotherapy, nuclear medicine study, or outpatient procedures. This process should be authorized by the medical staff and approved by the board. The Medical Executive Committee is often empowered to approve policies on behalf of the Medical Staff. Hospitals should ensure they are meeting the needs of their patients and that these are provided in accordance with standards of care and practices, with appropriate equipment, trained staff and an appropriate facility. Hospitals must ensure compliance with the CMS conditions of participation if they provide outpatient services.

You can find all the survey memos on the CMS website.