Revenue Cycle

First of 2012: CMS announces supervision decisions for select services

Patient Access Weekly Advisor, June 13, 2012

In the 2012 outpatient prospective payment system (OPPS) final rule, CMS established a process to utilize the hospital outpatient payment panel to recommend the appropriate levels of supervision for individual hospital outpatient therapeutic services. Following panel meetings at or around March and August of each year, CMS said it would consider panel recommendations and post decisions regarding individual services on its website. From there, there would be a 30-day waiting period for providers to make comments on the decisions, which would then lead to the finalized decisions going into effect in July or January, depending on the panel meeting.

For the most recent panel meeting, however, the initial determination was not well announced, and the ability to request determinations and make comments may have slipped by unnoticed for many providers, according to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc.

“I knew that determinations were supposed to be released for comment, yet I didn’t see anything on the website or hear anything on the open door forums, so I thought that perhaps the first panel meeting would be held in August due to the short time between the final rule and the first proposed meeting,” she says. “But CMS did display the recommendations for comment and finalize them, although it was not well publicized.”

Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc, agrees, saying that, “As a regulatory specialist [at HCPro], one of my responsibilities is to stay cognizant of the endless stream of CMS announcements, but I will admit that not only did this one slip by me, but any information related to the topic is also very difficult to find on the CMS website.”

According to the CMS release, the following services are now eligible to be performed under general supervision:

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

As a result of what could in effect be a lack of provider input, the list above comes off as perhaps a bit unexpected, says Hoy.

“Well first, 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 says. “Also, the inclusion of immunization codes, but no other drug administration codes seems odd.”

Hoy continues, “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.”

Critical access and rural hospitals

There had been hope that this panel and its recommendation process would help to alleviate some of the burden from smaller hospitals. For instance, in critical access hospitals—as CMS commentary reads now—physical therapy, occupational therapy, and speech language pathology are required to meet supervision requirements, meaning they must have a physician or NPP immediately available. However, for PPS hospitals, these services were exempted from the requirement because they are not paid under OPPS, explains Hoy.

“It’s interesting to me that this panel didn’t make the determination that PT, OT, and speech can be under general supervision, because this would have saved CAHs from having to have physicians immediately available, whereas other hospitals do not,” she says.

This puts CAHs and other rural hospitals in a tough spot, because their exception ends in January. The next opportunity for CMS to change supervision requirements is the August meeting, which would make any determinations effective on January 1. The problem here though, is that these hospitals won’t know until November or December whether or not they will be required to have supervision for some of these services starting in January leaving very little time to prepare, explains Hoy.

“This list does not address rural hospitals’ and critical access hospitals’ concerns at all. This process was supposed to address concerns that hospitals had with supervision requirements, but it doesn’t appear to have done much to alleviate their concerns for some of the most common services provided in hospital outpatient departments.”

To view CMS’ final decisions on the recommendations of the Hospital Outpatient Payment Panel on supervision levels for select services, click here:

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