CMS Eases Supervision Requirements For Outpatient Hospital Therapeutic Services

On November 27, 2012, the Centers for Medicare and Medicaid Services (CMS) issued finalized supervision requirements, effective January 1, 2013, on 22 outpatient hospital therapeutic services, further easing to a minimum of general supervision the restrictions that have significantly impacted hospitals since "clarifications" in CMS' calendar year (CY) 2009 Outpatient Prospective Payment System (OPPS) Final Rule. As required by the CY 2012 OPPS Final Rule, CMS requested input from the federal advisory Hospital Outpatient Payment Panel (Panel) regarding which supervision levels are appropriate for outpatient hospital therapeutic services. The final supervision requirements are the result of the Panel's recommendations regarding 29 individual hospital outpatient therapeutic services.

How Have CMS' Supervision Requirements Changed Since CY 2009

CMS' 2009 OPPS Final Rule, while purporting to restate and clarify rules in place since 2000, in fact revised supervision requirements for outpatient hospital therapeutic services, requiring direct physician supervision of therapeutic services furnished in both on-campus and off-campus outpatient departments. "Direct supervision" meant that a physician would be required to be in the outpatient hospital department.

In CY 2010 and 2011 OPPS Final Rules, CMS provided more flexibility to supervision requirements for outpatient hospital therapeutic services. The CY 2010 Rule gave hospitals more flexibility by allowing non-physician practitioners (NPPs) to supervise outpatient therapeutic services and by allowing "direct supervision" to be provided from anywhere in the main hospital or on the hospital's campus. Supervision of therapeutic services in off-campus outpatient departments, however, continued to require physicians and NPPs to be present in the outpatient department.

Further easing of supervision requirements occurred in CMS' CY 2011 OPPS Final Rule in two major ways. First, CMS classified certain services as "nonsurgical extended duration therapeutic services" (NSEDTS). Those services typically last for some period of time, require monitoring by auxiliary personnel, are not primarily surgical services, and do not require the physician's or NPP's immediate availability after they are initiated. The CY 2011 OPPS Rule required direct supervision of "extended duration services" only during the initiation of the service. After the service's initiation, general supervision could be provided at the supervising physician's or NPP's discretion. Second, the "direct supervision" was revised to mean that the supervising physician or NPP be "immediately available" to either the on-campus or off-campus outpatient department to "furnish assistance and direction throughout the performance of the procedure." Neither the physician nor the NPP was required to be "present in the room when the procedures is performed."

Recognizing that overall review of the supervision requirements would be beneficial, in its CY 2012 OPPS Rule, CMS designated the Panel to evaluate the appropriate level of supervision for outpatient hospital therapeutic services.

Consequences of the Panel's Recommendations, Comments, and CMS' Final Decision

CMS's final decision is that, of the 29 services recommended by the Panel, only 22 services must receive a minimum of general supervision. "General supervision" means that a procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure.

The following are outpatient therapeutic services that must have minimum of general supervision, including the majority of wound care, bladder irrigation services, subcutaneous and intramuscular drug/substance injections, and drug/substance intravenous administration services (as the patient receives additional dose of same drug/substance):

• HCPCS code G0008 Administration of influenza virus vaccine
• HCPCS code G0009 Administration of pneumococcal vaccine
• HCPCS code G0010 Administration of hepatitis B vaccine
• HCPCS code G0127 Trimming of dystrophic nails, any number
• CPT code 11719 Trimming of nondystrophic nails, any number
• CPT code 36000 Introduction of needle or intracatheter, vein
• CPT code 36591 Collection of blood specimen from a completely implantable venous access device
• CPT code 36592 Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified
• CPT code 51702 Insertion of temporary indwelling bladder catheter; simple (e.g., Foley)
• CPT code 51705 Change of cystostomy tube; simple
• CPT code 51798 Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging
• CPT code 96360 Intravenous infusion, hydration; initial, 31 minutes to 1 hour
• CPT code 96361 Intravenous infusion, hydration; each additional hour (list separately in addition to code for primary procedure)
• CPT code 96521 Refilling and maintenance of portable pump
• CPT code 96523 Irrigation of implanted venous access device for drug delivery systems
• HCPCS code G9141 Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family)
• CPT code 29580 Strapping; Unna boot
• CPT code 29581 Application of multi-layer compression system; leg (below knee), including ankle and foot
• CPT code 51700 Bladder irrigation, simple, lavage and/or instillation
• CPT code 96366 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (list separately in addition to code for primary procedure)
• CPT code 96372 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular
• CPT code 96376 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/ drug provided in a facility (list separately in addition to code for primary procedure)

*Note that HCPCS code G9141 is being deleted on December 31, 2012.

Seven of the Panel's recommendations were not accepted, however, because CMS viewed the services as either involving physician assessment or providing a significant potential for patient complications, adverse reactions, or other needs of the individual patient. Therefore, seven services will maintain their current designation as NSEDTS or "extended duration services" which require a supervising practitioner to be immediately available to the patient (i.e., direct supervision) at the initiation of the procedure.

• HCPCS code G0378* Hospital observation service, per hour
• HCPCS code G0379* Direct admission of patient for hospital observation care
• CPT code 96365* Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
• CPT code 96367* Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (list separately in addition to code for primary procedure)
• CPT code 96368* Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (list separately in addition to code for primary procedure)
• CPT code 96374* Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug
• CPT 96375* Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (list separately in addition to code for primary procedure)

Hospital observation services and a number of IV infusion services are among these therapeutic services that will continue to require that a supervising physician or NPP be immediately available at the initiation of the service followed by a minimum of general supervision at the physician's or NPP's discretion.

Those outpatient therapeutic services not listed in the "Supervision File – Hospital Outpatient Therapeutic Services" table require a minimum of "direct supervision." To view this file, please click here. To see a detailed history of the supervision regulation through the years, please see "Regulation Through the Years" under Related Files to the left of this article.

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