Last November I posted information on CMS' new interpretation of their Direct Supervision Rules, Direct Supervision Rules Have Changed.  Since that post I have recevied a number of additional questions and am posting my answers here for all to see.

Question #1

Does this ruling apply to Home Health and Physical Therapy as well as Wound Care Departments?

These rules are specific to all services rendered under the umbrella of HOPPS.  Home Health Services are billed under the HH-PPS and not the HOPPS.

This supervision requirement applies to the category of outpatient services covered as "incident to" a physician’s services. Certain hospital outpatient services (e.g., physical therapy) have their own benefit category and therefore are not subject to these supervision rules.

Question #2

Does it apply to simple dressing changes as opposed to debriding and hyperbaric units?

Pursuant to Section 42 C.F.R. Section 410.27 (the “Outpatient Therapeutic Services Regulation”), therapeutic services which hospitals provide on an outpatient basis are those services and supplies (including the use of hospital facilities) which are “incident to” the services of physicians in the treatment of outpatients. This regulation requires that services furnished at a department of a hospital, that has Medicare provider-based status, must be under the direct supervision of a physician. "Direct supervision" means the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.  Outpatient wound care done in a physician directed clinic is considered “incident to” the services of the ordering physician.

Question #3

If a Nursing Home or LTC facility has to have a physician or NP in house for a wound care nurse to render treatment, do these facilities have a qualified person on staff 24/7?

Like Home Health, Skilled Nursing Home’s and LTC facilities are not billed under the HOPPS guidelines and are subject to the rules that govern their own perspective payment systems not the Hospital Outpatient Perspective Payment System.

There is no such specified requirement for hospital inpatient services.

Question #4

How do ostomy appliance changes and peristomal care fit into this mix?

If these services are being billed as an outpatient therapeutic service, they too are considered to be a therapeutic service that is “incident to” the physician and would have to meet the same direct supervision requirements.