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  • CMS Revises Interpretative Guidelines for Rehabilitation in Outpatient Hospitals

    In response to concerns raised by APTA and other associations, the Centers for Medicare and Medicaid Services (CMS) revised interpretative guidelines (Transmittal 72) to eliminate the requirement that rehabilitation services furnished in outpatient hospital settings be ordered by a practitioner with medical staff privileges. The new guidance issued to the State Survey Agency Directors on February 17 is effective immediately and includes the following language:

    Requirements for Ordering Hospital Outpatient Services: Outpatient services in hospitals may be ordered (and patients may be referred for hospital outpatient services) by a practitioner who is:

    • responsible for the care of the patient;
    • licensed in, or holds a license recognized in the jurisdiction where he/she sees the patient;
    • acting within his/her scope of practice under state law; and
    • authorized by the medical staff to order the applicable outpatient services under a written hospital policy that is approved by the governing body. This includes both practitioners who are on the hospital medical staff and who hold medical staff privileges that include ordering the services, as well as other practitioners who are not on the hospital medical staff, but who satisfy the hospital's policies for ordering applicable outpatient services and for referring patients for hospital outpatient services.

    Previous Guidance Superseded: This guidance supersedes the guidance for ?482.56(b) (Tag A-1132) and ?482.57(b)(3) (Tag A-1163) found in SC-11-28 (May 13, 2011) and State Operations Manual (SOM) Transmittal #72 (November 18, 2011).

    The hospital's medical staff policy for authorizing practitioners to refer patients for outpatient services must address how the hospital verifies that the referring practitioner who is responsible for the patient's care is appropriately licensed and acting within his/her scope of practice.

    Resolving this issue has been a high priority for APTA and its members. APTA believes that this language is a significant improvement. The Survey and Certification Policy Memorandum in its entirety will be available on CMS's Web site next week.


    • ok. great i think. question? What about md's working for hospital system choosing to refer to a non outpatient hospital physical therapy organization. Like a person who owns and runs a medicare certified orf, who is a pt in independent practice. In my region, the greater saint louis metropolitian area, the hospital systems expect all of their mds to only refer within their system.... even when the patient requests to see an independent pt , sometimes the md.... under scrutiny and direct pressure from her administration... states that she is required to keep this ancillary referral inhouse secondary to her agreement with the hospital. seriously.... this happens all the time. WHAT ARE YOUR GUIDELINES AND INTERPRETIVE PERCEPTUAL REALITIES IN THIS INSTANCE? When you get the chance check out to legislative bill I am working on in Missouri... UNFAIR HI CO PAYS AND EQUAL PAY 4 EQUAL SERVICES.(BILLS FOR BOTH PIECES OF LEGISLATION ARE IN THE HOUSE AND SENATE) Call me at 314.495.2209 for more info. Just to confirm I am a serious practitioner who is in alignment with the APTA on most issues. I will be surprized if this question/comment even receives a reply.

      Posted by shawn tucker on 2/25/2012 12:26 PM

    • Amen, brother!! As a private practice PT, I work in an area facing the same problems as Shawn. I KNOW that the local community hospital has practices akin to those stated by Shawn, and MDs are "under scrutiny and with direct pressure" to refer their patients to the hospital outpatient department. I just worte a comment on another "headline", wondering why the hospital outpatient departments have different reimbursement guidelines; i.e. no caps until October. Hopital departments have had the best reimbusements AND the least restrictive guidelines for years!!

      Posted by M. Kovar, PT on 2/28/2012 2:34 PM

    • I whole heartedly agree with the above. I am a practioner and own an orf. The hospital outpatient physical therapist have the same qualifications(usually have less experience than outpatient physical therapy owners) and yet are excempt from the laws that apply and limit non-hospital based outpatient coverage. The hospital physicians in my area are constantly under pressure to refer to the hospital. Why does the Stark law not apply to them. Why the reimbursement limit not apply to them? It is a shame that the hospitals can get away with this unfair, unjust practice and that the Government enable that. It absolutely does not make any sense. I have been an APTA private practice member for atleast 15+ years. Although, APTA has made strides, thia iaaue in my opinion takes precedence.

      Posted by Jaya on 4/4/2012 12:04 PM

    • Keep in mind that to operate under hospital based OP practice you must follow all the joint commission rules and regs that the hospital must from all the safety standards, drills, infection control, HR regs, the monitors we do are numerous; as well as all the the Dept of Public health in our state (CA) must personally come in and do an on-site visit prior to opening doors; we have to maintain licensure along with hospital. TJC rules and regs definately come at come at a cost; I concur that hospital OP sites should not place any pressure on MDs to refer...I can assure, Since i work in administration for a hospital which has 5 successful OPs we do not- but our reputation in the community is why our MDs and patients come to us and we have an active Marketing department so we get lots of referrals from non hospital based MDs; our outcomes sell this for us. We do discuss ethics and stark laws; we are appropriate in our relationships and have monitors for this; We routinely audit our sites for compliance wtih not just COP for CMS but with TJC standards; CARF standards; and CDPH (Ca Dept of Public Health ) standards; all policies are reviewed with applicability to Outpatient services. All OP facilities that accept medicare must follow COP for Medicare...i see many smaller clinics that do not appear to follow the CMS guidelines and certainly do not follow or practice all the TJC standards - I have often heard our patients say at xyz clinic they only saw the PT for 15 minutes the rest was furnished by an aide. They are suprised when they come to our clinics that it's one per hour; Students who say they carried a separate case load etc etc...we follow the rules. So I ask you to be judicious in not throwing all hospital OP clinics under the bus -and i would recommend you review what is entailed in order to be a hospital based OP clinic. You would be suprised. MJ

      Posted by MJ Jacobson, PT on 4/10/2012 8:27 PM

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