Corporate Compliance

Note from the instructor: Hospital Outpatient Payment Panel makes recommendations to CMS

Medicare Insider, April 8, 2014

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This week’s note from the instructor is written by Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro.
 
Hospital outpatient therapeutic services, such as emergency department or clinic visits, paid under OPPS or paid to critical access hospitals (CAH) on a cost basis must be furnished “incident to” a physician’s service to be covered. In order to qualify for “incident to” coverage, the service must be furnished on the order of a physician or non-physician practitioner in a hospital or provider-based department of the hospital, be furnished as an integral part of treating the patient, and be provided under the appropriate level of supervision (i.e., general, direct, or personal).
In 2012, CMS established the Hospital Outpatient Payment Panel as an independent review entity, which included stakeholders from the OPPS and CAH hospitals, to give CMS recommendations on the appropriate supervision levels for hospital outpatient therapeutic services. The panel meets in March and August and then CMS posts its preliminary decisions on the panel’s recommendations for a 30-day comment period. After the comment period, CMS issues their decisions, which become effective July 1 following the March meeting or January 1 following the August meeting.
 
On March 10, the panel met and proposed several changes to the current supervision requirements. CMS accepted the panel’s recommendations on several key outpatient services but rejected several others based on safety and standards of quality care.
One of the outcomes of the panel’s meeting is that CMS will change the following services from direct supervision to general supervision, meaning that the service must be furnished under the physician or non-physician practitioner’s overall direction and control but does not require they be present during the service:
 
  • G0176 - Activity therapy, such as music, dance, art, or play therapies not for recreation related to the care and treatment of patient's disabling mental health problems, per session (45 minutes or more)
  • 36593 - Declotting by thrombolytic agent of implanted vascular access device or catheter
  • 36600 - Arterial puncture, withdrawal of blood for diagnosis
  •  94667 - Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation
  • 94668 - Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent
However, CMS did not accept the panel’s recommendation to change eight specific chemotherapy administration services from direct supervision to general supervision because the CPT codes describe the injection and intravenous infusion of highly complex drugs or complex biological agents. Direct supervision will continue to be the requirement for these services; CMS is seeking further comment on the panel’s recommendation for consider at its August meeting. Specifically, CMS is looking for clinical input regarding the appropriate level of supervision for the initial and subsequent administrations of these drugs when provided in a hospital or CAH outpatient department.
 
Although the panel recommended that CPT 97597 (debridement of an open wound) be changed to general supervision, CMS did not accept the proposal, stating that this code includes sharp debridement which is generally not within the nursing scope of practice and therefore is not safe for general supervision. Keep in mind that hospitals paid under OPPS or CAHs paid under cost do not have to meet “incident to” requirements for physical therapy, occupational therapy, speech-language pathology services, diabetes outpatient self-management training, medical nutrition therapy, and kidney disease education.
 
In CY 2012, CMS also defined an exception to the direct supervision requirements and created a list of Non-Surgical Extended Duration Therapeutic Services (NSEDTS). These services must be provided under direct supervision during the initiation of the service followed by general supervision once the supervising physician determines the patient is stable and the remainder of the service can be delivered safely under general supervision. The supervising physician must document the transition from direct to general supervision in the patient’s medical record. This subset of services was created, in part, to assist CAHs in meeting supervision requirements for payment that were not consistent with their licensure requirements regarding physician and NPP staffing.  
 
CMS will designate CPT code 36430 (transfusion, blood or blood components)as an NSEDTS because it warrants direct supervision initially and has a low risk of adverse effects once the transfusion has begun.  
 
CMS agreed with the panel to change CPT code 96370 (subcutaneous infusion, each additional hour) from an NSEDTS to general supervision, since it describes a subsequent infusion of a previously administered drug that already required direct or extended duration supervision for the initial hour of infusion. However, CMS did not accept the panel’s recommendation to change the following services from NSEDTS to general because they involve administration of a new drug or substance:
  • 96369 - 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)
  • 96371 - Subcutaneous infusion for therapy or prophylaxis (specify substance or drug)
 
These preliminary decisions by CMS remain open to public comment through April 30; comments can be submitted via email to HOPSupervisionComments@cms.hhs.gov. Hospitals are always encouraged to provide their input and suggestions to CMS so that they may be considered in the final decisions that will become effective July 1, 2014.
 



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