CMS clarifies 2011 HOPPS proposal
The Centers for Medicare & Medicaid Services (CMS) has provided clarification of the term “direct supervision” in the 2011 Hospital Outpatient Prospective Payment System (HOPPS) proposed rule.

For services provided on-campus, direct supervision means the supervising physician or non-physician needs to be present on the campus of the hospital or critical-access hospital (CAH) and immediately available to provide assistance. The same rule is applicable to services provided in off-campus remote locations, i.e., the supervising physician or non-physician needs to be present in the off-campus location and immediately available to provide assistance.

CMS noted that Medicare does not make a payment to a physician under the Medicare Physician Fee Schedule (MPFS) when the physician solely provides the direct supervision of hospital outpatient procedures but furnishes no direct professional service to a patient. Therefore, it is the responsibility of the hospital to make arrangements for appropriate supervision levels of services to be met.

The agency also has said that the supervising physician or non-physician does not have to be from the specialty of the service that is being performed as long as he or she is able to perform the procedure under a hospital-given privilege and within his or her scope of practice.

New policies were proposed for small and rural hospitals, as well as community CAHs. According to the CMS, the proposed rule permits a two-phase supervision requirement to the nonsurgical-extended-duration therapeutic services. The requirement allows direct supervision for the initiation of the service, which is followed by general supervision for the remainder of the services.

For diagnostic testing, CMS recommended following the supervision level requirements that are listed in the MPFS Relative Value File. The 2011 HOPPS proposed rule referred the issue of whether clinical nurse-midwives should be allowed to provide supervision for diagnostic tests to be addressed in the 2011 MPFS proposed rule.

CMS defined initiation of the service as the beginning portion of the procedure, which ends when the patient becomes stable and when the supervising physician or non-physician believes the remainder of the procedure may be delivered safely under general level supervision.

For a service to be considered a nonsurgical-extended-duration therapeutic service, it must meet the following criteria:
  • Must be of extended duration (frequently extending beyond normal business hours is not surgical);
  • Consists of a significant monitoring component, which is typically conducted by nursing or other auxiliary staff; and
  • Is low risk, such that it would not require direct supervision often during the performance of the procedure.

The agency will not exclude all outpatient CAH services from supervision requirements because it believes that CAHs are better positioned as they are reimbursed at 101 percent for their services and can afford to hire enough staff to provide direct supervision.

CMS is collecting comments on a requirement questioning whether or not the point of transfer from direct to general supervision should be documented in the patient’s medical record. In addition, the agency is seeking information on requiring hospitals to develop internal guidelines and protocols for every nonsurgical-extended-duration therapeutic service.