Corporate Compliance

Note from the Instructor: CMS Posts Hospital Outpatient Supervision Documents

Medicare Insider, December 16, 2014

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This week’s note from the instructor is written by Debbie Mackaman, RHIA, CPCO, regulatory specialist for HCPro.  
Last week, CMS posted a document on its Advisory Panel on Hospital Outpatient Payment website regarding hospital outpatient therapeutic services that were evaluated for a change in supervision levels.  The three page document contains a chart that includes the HCPCS code, level of supervision required for coverage, and the effective dates of the changes for various services.
Hospital outpatient therapeutic services paid under OPPS or paid to critical access hospitals (CAHs) 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 meet four requirements:
1.      The service must be furnished in the hospital or a provider-based department of the hospital;
2.      There must be an order for the service;
3.      The service must be an integral, though incidental, part of a physician’s service; and
4.      The service must be provided under the correct level of physician supervision.
CMS began amending and clarifying the requirements for supervision extensively in 2010 and this process continues under the Hospital Outpatient Payment Panel subregulatory process. In most cases, CMS has designated direct supervision to be the default level of supervision for hospital outpatient therapeutic services.
CMS also designated general supervision as appropriate for specific services based on recommendations from the Panel and provider comments. General supervision requires the service is furnished under the physician or non-physician practitioner’s (NPP’s) overall direction and control, but does not require them to be present during the service. Effective for dates of service January 1, 2015, CMS has listed the following as requiring general supervision when provided in a hospital outpatient department, including provider-based departments:
  • 99490 Chronic care management service, 20 minutes;
  • 99495 Transitional care management, 14 days post discharge; and,
  • 99496 Transitional care management, 7 days post discharge.
Several years ago, CMS defined a list of non-surgical extended duration therapeutic services (NSEDTS) which must be provided initially under direct supervision and then may be transitioned to general supervision once the supervising physician or NPP determines the patient is stable and the remainder of the service can be delivered safely under general supervision. This transition must be documented in the patient’s medical record. In the notice just published, there were no changes listed for NSEDTS in 2015.
Also included on the CMS website, which will be of interest for CAHs and small rural hospitals, is a brief notice stating non-enforcement of supervision requirements for these providers will continue through December 31, 2014 as afforded through H.R. 4067. 
Beginning in 2010, CMS instructed its contractors not to enforce the supervision requirements for therapeutic services provided to outpatients in CAHs and further expanded the non-enforcement to small rural hospitals in 2011. The non-enforcement instruction expired for the hospitals on January 1, 2014 and since then, there has been a lot of activity through various lobbying groups and organizations.  The Protecting Access to Rural Therapy Services (PARTS) Act, which will now have to be reintroduced in 2015 under the new Congress, was intended to permanently change supervision levels from direct to general for therapeutic outpatient services which are not high risk or complex for certain hospitals. Through the passing of H.R. 4067, CAHs and small rural hospitals have dodged the supervision bullet once again by receiving a one year extension.

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