Knowledge Base Article

Most of us know the dangers of assumptions. We have all heard the play on letter divisions within the word “ass/u/me.” Medicare and Medicare providers are not immune to the negative consequences of assumptions. Such was the case with the physician supervision rules for hospital outpatient services.

In the 2009 Outpatient Prospective Payment System (OPPS) Proposed and Final Rules, Medicare shocked the provider community with their “clarification” of the physician supervision requirements. Prior to this “clarification,” hospitals had not worried much about meeting the physician supervision requirements on the hospital campus because CMS stated in the original OPPS rule that “we assume the physician supervision requirement is met on hospital premises because staff physicians would always be nearby within the hospital.” But according to Medicare, providers misinterpreted their meaning of the word “assume” and Medicare always expected hospital outpatient therapeutic services to be provided under the direct supervision of physicians in the hospital and in all provider-based departments (PBDs) of the hospital, specifically, both on-campus and off-campus departments of the hospital.

Thus began the on-going discussions, clarifications, adjustments, and exceptions to physician supervision requirements for hospital services. So where are we today with supervision requirements for hospital outpatient services?

Therapeutic Services

Generally, “CMS requires direct supervision by an appropriate physician or non-physician practitioner in the provision of all therapeutic services to hospital outpatients, including CAH outpatients.”

Facts about Direct Supervision:

• Applies to therapeutic services furnished in the hospital or CAH or in an on-campus or off-campus outpatient department of the hospital or CAH.
• Non-physician practitioners (NPPs) may furnish the required supervision of hospital outpatient therapeutic services that they are allowed to personally furnish. NPPs include licensed clinical social workers, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives.
• The physician or NPP must be immediately available to furnish assistance and direction throughout the performance of the procedure. Immediately available means the immediate physical presence of the supervisory physician or NPP.
• The physician is not required to be present in the room where the procedure is performed or within any other physical boundary as long as he or she is immediately available.
• Lack of immediate availability would be situations where the supervisory physician is performing another procedure or service that he or she could not interrupt.
• Though not specifically defined in terms of time or distance, the supervisory physician or NPP may not be so physically distant on-campus from the location where hospital/CAH outpatient services are being furnished that he or she could not intervene right away.
• An allowed practitioner can furnish direct supervision from any location in or near an off-campus hospital or CAH building that houses multiple hospital provider-based departments where the services are being furnished as long as the supervisory practitioner is immediately available.
• The supervisory physician or NPP must have, within his or her State scope of practice and hospital-granted privileges, the knowledge, skills, ability, and privileges to perform the service or procedure.
• CMS expects the supervisory practitioner to be knowledgeable about the therapeutic service and clinically able to furnish the service.
• The supervisory responsibility is more than the capacity to respond to an emergency, and includes the ability to take over performance of a procedure or provide additional orders.
• The supervisory practitioner must be clinically able to supervise the service or procedure.
  This means an ER physician does not meet the supervision requirements for a specialized service such as Radiation Oncology.
• The moratorium on enforcement of direct supervision requirements for CAHs and rural hospitals has expired. For 2015 and beyond, CMS requires a minimum of direct supervision for all outpatient therapeutic services furnished in all hospitals, including rural hospitals and CAHs, unless different supervision requirements are assigned as explained below.

CMS may assign certain hospital outpatient therapeutic services either general supervision, personal supervision or extended duration services supervision.

• General supervision means the procedure or service is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure.
• Personal supervision requires the physician must be in attendance in the room during the performance of the service or procedure.
• For nonsurgical extended duration therapeutic services (“extended duration services”), CMS requires a minimum of direct supervision during the initiation of the service which may be followed by general supervision for the remainder of the service at the discretion of the supervisory practitioner.
• “Initiation” means the beginning portion of the extended duration service, ending when the supervisory practitioner believes the patient is stable enough for the remainder of the service to be safely administered under general supervision.
• The point of transition to general supervision must be documented in the patient’s progress notes or medical record.
• The list of services that may be furnished under general supervision or that are defined as non-surgical extended duration therapeutic services is available on the Hospital OPPS Webpage.

Diagnostic Services

Payment is allowed under the hospital outpatient prospective payment system for diagnostic services only when those services are furnished under the appropriate level of supervision.

• Supervision levels for diagnostic tests are listed in the quarterly updated Medicare Physician Fee Schedule (PFS) Relative Value File. For guidance regarding the numeric levels assigned to each CPT or HCPCS code in the PFS Relative Value File, see the Medicare Benefit Policy Manual, Chapter15, Section 80, “Requirements for Diagnostic X-ray, Diagnostic Laboratory, and Other Diagnostic Tests.”
• The definitions of “general” and “personal” supervision listed above apply.
• “Direct supervision” means that the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure following the same rules for direct supervision as discussed above. This applies to diagnostic services provided:
• Directly or under arrangement,
• In the hospital or in an on-campus or off-campus outpatient department of the hospital.
• Non-physician practitioners cannot provide the required physician supervision when other hospital staff are performing diagnostic tests.

For more information on supervision requirements, see the Medicare Benefit Policy Manual, Chapter 6, sections 20.4.4, 20.5.2, and 20.7.

It is unknown if or how Medicare will enforce these supervision requirements, but we definitely don’t want to “assume” they will not.