The CMS 2011 OPPS final rule was released on November 2, 2010.   CMS has made several changes to physician supervision requirements for hospital outpatient services. Most hospitals will welcome the new changes which generally provide some relief to the strict physician supervision requirements for small rural hospitals and critical access hospitals. These changes will be effective January 1, 2011.  

In the 2011 OPPS Final Rule, CMS:

• Changed the definition of "immediately available"
• Delayed enforcement of supervision requirements for rural and critical access hospitals (CAHs)
• Announced its plan to convene a panel beginning in 2012 to determine the level of supervision required for different services
• Finalized a new category of "nonsurgical extended duration therapeutic services" that require direct supervision during an initiation period, followed by a minimum standard of general supervision


Physician Supervision

The final rule has changed the definition of "direct supervision" for on-campus hospital outpatient departments and off-campus provider-based departments.  The definition of direct supervision has been revised simply to require immediate physician availability, meaning that the physician is physically present, interruptible, and able to furnish assistance and direction throughout the performance of the procedure but without reference to any particular physical boundary. As a result of the change, physicians providing direct supervision in on-campus outpatient departments will no longer be limited to the hospital's campus. So long as the physician remains physically available, interruptible and can provide assistance at any notice, the direct supervision requirement will be met. Similarly, physicians providing direct supervision in off-campus provider-based departments will no longer need to remain within the walls of the off-campus provider-based department to meet the new definition of direct supervision. This change provides hospitals some additional flexibility with regards to direct supervision requirements.

The final rule has stated that CMS will not enforce the direct supervision requirements for therapeutic services furnished in critical access hospitals (CAHs) and rural hospitals with 100 ore fewer beds during 2010 and 2011.  This change extends and expands the enforcement delay that CMS previously announced in March.

Non-Surgical Category of Services

The final rule has established a new category of services called "non-surgical extended duration therapeutic services," which require direct physician supervision during the services' "initiation period." The initiation period has been defined as the "beginning portion of the non-surgical extended duration therapeutic service which ends when the patient is stable and the supervising physician believes the remainder of the service can be delivered safely under general supervision without the physician's presence on the hospital campus or in the PBD of the hospital."

CMS selected 16 services to include in the new category of nonsurgical extended duration therapeutic services, including observation, intravenous infusion, subcutaneous infusion, and therapeutic, prophylactic, or diagnostic injections. When selecting the services for the new category, CMS stated the services must:

• Be of extended duration, frequently extending beyond normal business hours
• Largely consist of a significant monitoring component typically conducted by nursing or    other auxiliary staff
• Be of sufficiently low risk, such that the service typically would not require direct supervision often during the service
• Not be a surgical service that includes recovery time

CMS defines "initiation of the service" as the beginning portion of a service. It ends when the patient is stable and the supervising physician or appropriate non-physician practitioner believes the remainder of the service can be delivered safely under his or her general direction and control without the physician's physical presence on the hospital campus or in the provider-based department of the hospital.

This new category of services does not currently apply to critical access hospitals or rural hospitals because CMS has temporarily suspended enforcing physician supervision requirements for them.

The OPPS final rule announced that CMS is considering using CMS’ Federal Advisory Panel on Ambulatory Classification Groups (APC Panel) as the independent technical committee that would review requests for consideration of supervision levels and make recommendations to CMS regarding the appropriate levels.

Reporting ancillary services with critical care

Another significant change comes as a result of a change by the CPT Editorial Panel, which is revising its guidance for critical care codes 99291 and 99292 to specifically state that, for hospital reporting purposes, critical care codes do not include the specified ancillary services.

This means beginning in CY 2011, hospitals can and should report in accordance with the CPT guidelines that will allow the separate reporting of ancillary services and associated charges when provided in conjunction with critical care. These ancillary services include, but are not limited, to chest x-rays and pulse oximetry.  However CMS will not make separate payment for the ancillary service because CMS states it has already factored those costs into the development of the critical care APC payment rate from historical claims data where the cost of these services was included in the critical care charge.

This is great news for the hospital community because they have been trying individually through comment letters and through the AHA to get CMS and/or the AMA through the CPT Editorial Panel to realize that hospitals should be allowed to report and obtain payment for these ancillary services in addition to the reporting and payment for the critical care service.

CMS is requesting comments on this issue so hospitals should provide feedback on how CMS should treat the revision of the CY 2011 critical care codes for the future, especially with respect to generating separate payment. The rule covers other changes, including:

• An increase to the drug packaging threshold from $65 to $70
• A slight increase in separately payable drug reimbursement from ASP + 4% today to ASP+5% in the future
• Removal of three codes from the inpatient-only list
• Co-insurance and deductibles for preventive services
• Wound care coding and payment
• The outpatient hospital quality initiative

For a copy of the 2011 OPPS final rule, click on the following link to the CMS OPPS website

https://www.cms.gov/HospitalOutpatientPPS/HORD/list.asp