Revenue Cycle

Physician supervision enforcement for CAHs: Part 1

Medicare Update for CAHs, July 25, 2012

On July 6, CMS released a display copy of the 2013 OPPS proposed rule. In the rule, CMS issued proposed guidance that would once again extend the non-enforcement of supervision rules for critical access hospitals (CAH) and small rural hospitals for another year. This potential extension may tie into the fact that the most recent hospital outpatient payment panel meeting did not necessarily address some of the burdens that smaller hospitals face.

There had been hope that the panel—which now includes CAHs—and its recommendation process would specifically address the issues that CAHs and rural hospitals face with physician supervision. Instead, the panel made a number of determinations that may have left affected providers wanting more. The following services are now eligible to be performed under general supervision:

  • Specific mental health services from the code range 90804-90828, which excludes codes for medical evaluation and management; 90846-90857; G0177; G0410 and G0411
  • Bladder catheter insertion, code 51701
  • Immunization administration, codes 90471-90474
  • Smoking cessation counseling, codes 99406-99407

Perhaps due to a lack of provider input, the above list may seem unexpected, said Kimberly Hoy, JD, CPC, director of Medicare and complianceat HCPro, Inc. in a June 13 HCPro article.

“The list contains a number of psychotherapy codes, but one of the main providers of psychotherapy services—clinical psychologists—can themselves supervise these services, so their inclusion on the list comes as a bit of a surprise,” she said. “Also, the inclusion of immunization codes, but no other drug administration codes seems odd.”

Hoy continued, “Also, I would have assumed that observation may have been one of the very first issues that was addressed by the panel; either confirming or denying whether or not it’s a service that can be performed under general supervision. This continues to be an issue for critical access and rural hospitals that is not solved by the Non-Surgical Extended Duration Service exception CMS created.”

So as it stands now, the exception for CAHs and other rural hospitals ends in January and the next opportunity of CMS to change supervision requirements is at the August panel meeting, which would make any determinations effective on January 1. This puts these hospitals at a disadvantage because they won’t know until November or December whether or not supervision requirements for certain services have changed for them. 

CMS has clearly indicated that this will be the last year that CAHs will be able to disregard the direct supervision portion of the “incident to” regulation for providing outpatient therapeutic services, says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

“Because CAHs can face considerable challenges in recruiting additional medical staff to their rural hospitals—which may be necessary to meet the supervision requirements after 2013— this may be good news for CAHs because it allows them one more year to develop their strategy to comply with the direct supervision rules.”

CMS is also requesting that CAHs and other small rural hospitals submit to CMS for evaluation by the Panel at the summer meeting any services for which they anticipate difficulty complying with the direct supervision standard in 2013. CMS states that “hospitals should refer to the evaluation criteria that it finalized in the CY [calendar year] 2012 OPPS/ASC final rule when making these submissions.” 

Consequently, CMS anticipates extending the nonenforcement instruction for one final year, through CY2013, so that hospitals have additional time to become familiar with the submission and review processes and to allow hospitals time to meet the required supervision levels for services that may be considered for CY 2013. In the meantime, however, CAHs should take action, says Mackaman.

CAHs should address the supervision challenges sooner, rather than later, through staffing and scheduling,” she says. “When hospitals are allowed to put off the inevitable for multiple years, the urgency of resolving this issue takes the backburner for other current compliance issues that are staring them down. After all, the solution to this problem may cost a CAH significant money.”

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