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Medical Coding News Archives

A Compromise for Outpatient Therapeutic Services Supervision Requirements

 
August 16, 2010:

For calendar year 2011, the Centers for Medicare and Medicaid Services (CMS) is proposing somewhat of a compromise in the supervision policy for therapeutic services that will apply to all hospitals, including critical access hospitals (CAHs).

In 2000, CMS established as a condition for payment under the outpatient prospective payment system (OPPS), the requirements for physician supervision of diagnostic and therapeutic services provided to hospital outpatients incident to a physician’s service. The various payment requirements for physician supervision of therapeutic and diagnostic services have been clarified and restated several times since 2000.

Supervision in the hospital outpatient setting has been defined by drawing on the three levels of supervision defined for the physician office setting: general, direct, and personal. General supervision means that a service is furnished under the physician’s overall direction and control but his or her physical presence is not required during the performance of the procedure. Direct supervision means that the physician is physically present onsite and is immediately available to furnish assistance and direction throughout the performance of the procedure; the physician does not have to be present in the same room when the procedure is being performed. Personal supervision means the physician is present in the room when the service is being performed.

The compromise CMS is proposing involves identifying a limited set of specific services that are not surgical services but include a significant monitoring component that may last a considerable amount of time. These services usually have a low risk of complication following the assessment incurred at the beginning of the service and are designated as “nonsurgical extended duration therapeutic services.” Such services would require direct supervision only for the initiation of the service, followed by general supervision for the remainder of the service. The definition of general supervision is the same as that recognized under the Medicare physician fee schedule.

Four criteria were used to identify the list of nonsurgical extended duration therapeutic services to which this new policy of direct supervision during the initiation of the service followed by general supervision for the remainder of the service would apply.

1. The service would be of extended duration, frequently extending beyond normal business hours.
2. The service would consist largely of a significant monitoring component typically conducted by nursing or other auxiliary staff.
3. The service must be of sufficiently low risk such that it typically would not require direct supervision often during the service.
4. The service is not primarily surgical in nature.

PROPOSED LIST OF NONSURGICAL EXTENDED DURATION THERAPEUTIC SERVICES

HCPCS Code

Long Description

C8957

Intravenous infusion for therapy/diagnosis; initiation of prolonged infusion (more than 8 hours), requiring use of portable or implantable pump

G0378

Hospital observation service, per hour

G0379

Direct admission of patient for hospital observation care

96360

Intravenous infusion, hydration; initial, 31 minutes to 1 hour

96361

Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)

96365

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour

96366

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to  code for primary procedure)

96367

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure)

96368

Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)

96369

Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of  subcutaneous infusion site(s)

96370

Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)

96371

Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure)

96372

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

96374

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug

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)

96376

Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided

CMS proposes defining “initiation of the service” as the beginning portion of a service ending when the patient is stable and the supervising physician or appropriate nonphysician practitioner believes the remainder of the service can be performed 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. The agency does not propose to further define the term “initiation” or to set time limits on this portion of the service because it feels that the determination that a patient is sufficiently stable to transfer from direct supervision to general supervision, and the timing of that decision, are clinical judgments. However, CMS is considering whether the point of transfer from direct supervision to general supervision should be documented in the medical record or identified in a hospital protocol.

Regina Magnani, RHIT
Clinical/Technical Editor, Coding Solutions

 

 
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