Valerie Short, RN, ACHRN, CWCN, CWS, CMBS, FACCWS
Director of Operations & Compliance
National Baromedical Services, Inc.
Effective January 1, 2020, the minimum required level of supervision for hospital outpatient therapeutic services changed from direct to general supervision. At first blush, this is a big deal. It caught many providers off guard, especially as it seems to contradict Local Coverage Determinations (LCDs) for reimbursement. I consulted with various Medicare Administrative Contractors (MACs) and closely studied details of the final rule.
The reason for this change is multifaceted. First, this ruling applies to all outpatient therapeutic services provided in hospital provider based departments. Previously, this caused hardship for critical access and small rural hospitals, as they do not always possess the physician staff required to provide direct supervision. Holding them to this standard would deny patients access to many critically necessary services. CMS exempted these hospitals and essentially maintained a two-tiered system for supervision requirements to honor their non-enforcement agreement. Non-enforcement expired this year, making it the perfect time to re-evaluate supervision requirements for all hospitals. Having a uniform level of supervision required for all hospitals is easier for CMS to monitor and enforce.
CMS recognizes that most outpatient therapeutic services represent a level of complexity and risk significant enough that direct supervision will remain hospital policy, regardless of the lower level CMS now requires. CMS has always emphasized that ultimately, physicians and hospitals are responsible for ensuring patient safety.
CMS also recognized that it is extremely difficult and inefficient to try to audit and monitor appropriate safety and supervision of all therapeutic services through hospital payment systems, which are not conducive to auditing safety and provision of care. CMS further recognized that facility medical staff by-laws and CMS Conditions of Participation have regulations in place better designed to monitor compliance.
How specifically does this new rule impact provision of wound care and hyperbaric treatments? The OPPS Final Rule only deals with Part A (hospital billing and payment). Therefore, clinical facility reimbursement for G0277 has been the only aspect affected by any failure to comply with the previous requirement to provide and document direct supervision. Determining compliance required a manual audit of records, which was labor intensive and did nothing to improve overall safety of care provided to patients with respect to physician oversight. Rather than require direct supervision for G0277 under a rule that applies to all outpatient therapeutic services, CMS changed the supervision level under OPPS to “general”. However, CMS has specifically stated to the various MACs that the change from direct to general supervision does not change the need to associate CPT code G0277 with 99183 in the electronic billing/reimbursement edits. By allowing the edit to exist, monitoring compliance becomes an automatic electronic process.
Going forward in 2020, whenever CPT code G0277 is billed on a claim, the system will expect to see a correlating claim with a charge for 99183 as well. The descriptor for CPT code 99183 reads, “attendance (my emphasis) and supervision…”. In order to meet the attendance aspect of the definition, the physician must personally provide some aspect of care to the patient. CMS finds the definition of 99183 very similar to an evaluation and management (E&M) code. In order to charge this service, the physician must personally provide a service to the patient to substantiate a charge. CMS felt this protected the patient from having unsupervised wound care and hyperbaric treatments because the physician must provide a level of service that would clearly be greater than general supervision. Just being available by phone does not meet the definition of that CPT code.
At the time of this writing, no MAC has been provided any directive by CMS to issue any changes to coverage policies. MACs may change the word “direct” supervision to “appropriate” supervision, but the expectation for physician oversight has not changed.
Bottom line: Although the Part A requirement under OPPS has changed the supervision level from direct to general, do not change your physician coverage practices for wound care and HBO. This change is merely a shift in where auditing and enforcement actions will take place, not that the expectation for direct physician supervision has gone away.