Revenue Cycle

CMS revises Medicare Conditions of Participation for hospitals and CAHs

Medicare Update for CAHs, May 30, 2012

On May 9, CMS released two rules aimed at reducing regulatory burdens for healthcare providers. One of the published rules is a revision of the Medicare Conditions of Participation (CoPs) for hospitals and critical access hospitals (CAHs). In this rule, CMS has made a number of changes that it ultimately hopes will save hospitals and CAHs approximately $940 million per year.

Medicare’s CoPs are federal health and safety requirements that ensure high quality care for all of its patients, and both hospitals and CAHs must meet these conditions in order to participate in Medicare and Medicaid. According to the final rule, the regulatory burden on hospitals and CAHs will be reduced in a number of different ways. For CAHs in particular, the following CoPs were revised:

§ 485.604 Personnel qualifications

CMS has aligned the definition of ‘clinical nurse specialist’ that is in the rule with the definition that is in the statute.

(a)    Clinical nurse specialist. A clinical nurse specialist (CNS) must be a person who— (1) Is a registered nurse and is licensed to practice nursing in the State in which the clinical nurse specialist services are performed in accordance with State nurse licensing laws and regulations; and (2) Holds a master’s or doctoral level degree in a defined clinical area of nursing from an accredited educational institution.

§ 485.623 Condition of participation: Physical plant and environment

The CoPs for “Physical plant and environment” were revised as follows:

(a) Standard: Construction. The CAH is constructed, arranged, and maintained to ensure access to and safety of patients, and provides adequate space for the provision of services.

§ 485.635 Condition of participation: Provision of services

The CAH provides those diagnostic and therapeutic services and supplies that are commonly furnished in a physician’s office or at another entry point into the health care delivery system, such as a low intensity hospital outpatient department or emergency department. These CAH services include medical history, physical examination, specimen collection, assessment of health status, and treatment for a variety of medical conditions.

Laboratory services. The CAH provides basic laboratory services essential to the immediate diagnosis and treatment of the patient that meet the standards imposed under section 353 of the Public Health Service Act. The services provided include the following:

(i) Chemical examination of urine by stick or tablet method or both (including urine ketones).
(ii) Hemoglobin or hematocrit.
(iii) Blood glucose.
(iv) Examination of stool specimens for occult blood.
(v) Pregnancy tests.
(vi) Primary culturing for transmittal to a certified laboratory.

Radiology services. Radiology services furnished by the CAH are provided by personnel qualified under State law, and do not expose CAH patients or personnel to radiation hazards.

Emergency procedures. In accordance with requirements of § 485.618, the CAH provides medical services as a first response to common life-threatening injuries and acute illness.

CMS has eliminated the burdensome requirement that CAHs must furnish diagnostic and therapeutic services, laboratory services, radiology services, and emergency procedures directly by CAH staff. This will allow CAHs to partner with other providers (under arrangement) so they can be more efficient while at the same time, ensuring the safe and timely delivery of care to their patients, according to the CMS fact sheet.

§ 485.639 Condition of participation: Surgical services.

CMS has clarified that surgical services are an optional service at CAHs. The CoPs were revised as follows:

If a CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the governing body, or responsible individual, of the CAH in accordance with the designation requirements under paragraph (a) of this section.

Although any changes to the regulatory burden for hospitals are an improvement, and certainly create cost savings opportunities, a number of these changes appear to be minor in nature, suggests Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

“CAHs have not been required to provide surgical services, so the changes to § 485.639 are a clarification rather than a change in regulations,” she says. “In addition, the ability for CAHs to use a highly qualified CNS when recruiting non-physician practitioners to provide services in rural communities is helpful, but the  change that will have the biggest impact on CAHs is the ‘under arrangement’ revision.”

She continues, “Now that CAHs can furnish certain services ‘under arrangement’ rather than be required to provide laboratory, radiology, emergency procedures and other therapeutic and diagnostic services directly by CAH staff allows for more flexibility for CAHs to be able to provide a wider range of outpatient services.”

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