Hospital Outpatient Supervision Requirements Modified by CMS

1. On campus outpatient departments can have non-physician practitioners supervise outpatient therapeutic services according to their state's scope of practice rules.
2. Physicians must still supervise diagnostic services including pulmonary, cardiac, and intensive cardiac rehabilitation services.
3. "Direct supervision" has been modified to include anywhere within the main building(s) of the hospital or critical access hospital that is operated as part of the hospital. 
4. Physician supervision is still required for off-campus hospital outpatient departments with the physician being required to be in the provider-based department and not in the room where the procedure is performed.

CMS has modified the physician supervision requirements for hospital outpatient departments, relaxing previously issued strict and otherwise operationally-challenging requirements.  In the 2010 Outpatient Perspective Payment System final rule issued on October 30, 2009, CMS is issuing final rules that will go into effect on January 1, 2010 that will make hospital outpatient departments more operationally friendly as they relate to the physician supervision requirements.  Currently, CMS requires a physician to provide direct supervision in the actual department where the therapeutic services are performed.  The four significant changes that will go into effect on January 1, 2010, are described below.

First, for hospital departments within the hospital, including critical access hospitals, certain non-physician practitioners will be able to provide the supervision services for therapeutic services within the scope of their state's practice rules and hospital privileging requirements.  The non-physician practitioners included are:  physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives, and license clinical social workers.  Even though non-physician practitioners may be permitted to provide the supervision for the outpatient therapeutic services, hospitals need to ensure that the supervision is permitted by their state's scope of practice rules and that the hospital can document the specific individual, be it a non-physician practitioner or a physician, providing the supervision services during the operation of the hospital's outpatient department.

Second, even though a non-physician practitioner is able to provide supervision services for therapeutic services, physicians are still required to provide the supervision services for the following diagnostic services:  pulmonary, cardiac, and intensive cardiac rehabilitation services. 

Third, CMS has redefined "direct supervision" for on-campus hospital outpatient departments.  Direct supervision will be met as long as the physician or non-physician practitioner is within a main building of the hospital that is operated as part of the hospital and in which services are billed using the hospital's certification number.  CMS cautions, however, that the physician or non-physician practitioner must still be able to respond in a timely manner when issues arrive in the department.  Therefore, if the practitioner providing supervision does not remain within the department, the hospital must ensure, for quality reasons, that the practitioner will be able to respond in a timely manner.

Fourth, for off-campus provider-based departments, i) a physician must still provide the supervision, not a non-physician practitioner, and ii) the physician must remain in the department during the time the physician is providing the supervision services.  CMS made it clear that the physician does not need to be in the same room where the services are provided.  However, the physician must still remain within space that has been determined to be the provider-based department.  If a facility has multiple and separately designated provider-based departments, a physician must be in each department if services are provided at the same time that require supervision.  A physician cannot provide supervision services for multiple provider-based off-campus departments at the same time.