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From the National Rural Health Association

Archived 9/2/2011

CMS issued a notice yesterday regarding what has recently become a very hot topic: its recent physician supervision final rule (see NRHA’s blog post). After many NRHA, other association and individual meetings with Congressional staff, as well as multiple letters and calls to CMS from House and Senate members, CMS has delayed the requirements set forth in the 2010 Outpatient Prospective Payment System (OPPS) Final Rule for Critical Access Hospitals until the end of this year. Though we are still working to ensure CAHs are protected after 2010, and also to protect small PPS hospitals as well, this represents a welcome change in what could have had serious implications for CAHs.

Additionally, this change would not have been realized were it not for each and every individual who contacted CMS or their Congressional representatives. Without you helping to put this on their radar, Congress and CMS would have never understood the true affect this rule could have had on rural providers and patients.

The CMS Alert:

Subject: CMS Issues Notice on Supervision Requirements for Outpatient Therapeutic Services in Critical Access Hospitals

The Centers for Medicare & Medicaid Services (CMS) will instruct all of its Medicare contractors not to evaluate or enforce the supervision requirements for therapeutic services provided to outpatients in Critical Access Hospitals (CAHs) for the duration of calendar year (CY) 2010. The final 2010 hospital outpatient prospective payment system rule had specified that a “direct supervision” standard is required for therapeutic services furnished in hospital outpatient departments. CMS believed this requirement to be a clarification of longstanding policy, but the rule has generated concern among some rural providers who had previously interpreted the CMS policy to require only “general supervision” and who believe that it may be difficult to meet this requirement.

CMS plans to revisit the issue of supervision for therapeutic services provided to hospital outpatients in CAHs through the annual rulemaking cycle for CY 2011. CMS continues to expect CAHs to fulfill all other Medicare program requirements when providing services to Medicare beneficiaries and when billing Medicare for those services. While CMS is instructing contractors not to enforce the supervision requirements in CAHs for CY 2010, we continue to emphasize quality and safety for services provided to all patients in CAHs.

New Expansion of the National Practitioner Data Bank

Archived 9/2/2011

Effective March 1, 2010, the National Practitioner Data Bank (NPDB) is expanded through the implementation of Section 1921 of the Social Security Act. Section 1921 expands the NPDB by including adverse licensure information on all licensed health care practitioners and health care entities. It will also have certain final actions or recommendations to sanction that have been taken by Private Accreditation Entities and Peer Review Organizations.

Proposed Rule for the Establishment of Certification Programs for Health Information Technology

Archived 9/2/2011

A Message from Dr. David Blumenthal, National Coordinator for Health Information Technology March 2, 2010

Today the Secretary of the Department of Health and Human Services (HHS) released a notice of proposed rulemaking (NPRM) outlining the proposed approach for establishing a certification program to test and certify electronic health records (EHRs). The HITECH Act mandates the development of a certification program which will give purchasers and users of EHR technology assurances that the technology and products have the necessary functionality and security to help meet meaningful use criteria. While we are making significant strides toward modernizing our health care system, these efforts will only succeed if providers and patients are confident that their health information systems are safe and functional.

The proposed rule incorporates two phases of development for the certification program to ensure that eligible professionals and eligible hospitals are able to adopt and implement Certified EHR Technology in time to qualify for meaningful use incentive payments. The rulemaking process will take time, so this phased approach provides a bridge to detailed guidelines to support an ongoing program of testing and certification of health IT.

The first proposed program creates a temporary certification process under which the National Coordinator would authorize organizations to assume many of the responsibilities that will eventually be fulfilled under the permanent certification program. For the permanent certification program, the rule proposes transitioning much of the responsibility for testing and certification to organizations in the private sector.

Publication of the proposed rule on the Establishment of Certification Programs for Health Information Technology is an important first step in bringing structure and cohesion to the evaluation of EHRs, EHR modules, and potentially other types of health IT. The programs will help support end users of certified products, and ultimately serve the interests of each patient by ensuring that their information is securely managed and available where and when it is needed.

Your input is essential to bringing this important process to fruition. We encourage your participation in the open public comment period.

Additional information on both of these programs and how you can comment can be found through the HHS news release issued today and at the HealthIT website.

The vision of the HITECH Act is unfolding rapidly, and all of us at ONC look forward to continuing to work with you to achieve the meaningful use of EHRs.

CMS and ONC Issue Regulations Proposing a Definition of 'Meaningful Use'

Archived 9/2/2011

The CMS and ONC call on December 30, 2009 introduced two new regulations that were recently released. The interim final rule for “meaningful use” will be published in the January 13th Federal Register and you will have 60 days to comment. The other regulation is a proposed rule dealing with Medicare and Medicaid provisions with plenty of time to comment. This regulation proposes a three stage implementation focusing on improving clinical quality measures with increasing standards over time. The information below provides links to the appropriate documents.

The Oregon Office of Rural Health will continue to work closely with the OAHHS throughout 2010 to ensure you receive the latest information in a timely manner. If you have any additional questions, please feel free to contact Shellye Dant at or (503) 494-4450.

From the Rural Assistance Center (RAC)

Archived 9/2/2011

CMS and ONC Issue Regulations Proposing a Definition of ‘Meaningful Use’ and Setting Standards for Electronic Health Record Incentive Program Public Encouraged to Comment on New Regulations

The Centers for Medicare & Medicare Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) encourage public comment on two regulations issued today that lay a foundation for improving quality, efficiency and safety through meaningful use of certified electronic health record (EHR) technology. The regulations will help implement the EHR incentive programs enacted under the American Recovery and Reinvestment Act of 2009 (Recovery Act).

A proposed rule issued by CMS outlines proposed provisions governing the EHR incentive programs, including defining the central concept of “meaningful use” of EHR technology. An interim final regulation (IFR) issued by ONC sets initial standards, implementation specifications, and certification criteria for EHR technology. Both regulations are open to public comment.

H1N1 Waivers

Archived 9/2/2011

We have received many communications in the last few days about the H1N1 Emergency. We apologize for adding to the e-mail overload about H1N1, but we want to make sure you all have the latest information available to you. ORH is working closely with OAHHS, CMS, ORHP, and NRHA to receive the latest information on the outbreak and waiver process. We appreciate all the questions we have received and have forwarded them on to ORHP and CMS. Below are messages from ORHP, CMS, DHS, and NRHA regarding the bed limit waiver.

We are currently in the process of posting the latest information on the ORH website. We will continue to update our H1N1 Waivers page with all communications that we receive on this topic, so please bookmark our H1N1 Waivers page as a resource. If you have an immediate question, please contact Linda Lang with OAHHS directly at or 503.467.9910 Cell or 503.636.2204 Main. OAHHS is working closely with DHS, CMS and others to determine the steps necessary to get a waiver. We heard from CMS that CAHs will have to be at their bed 25-bed limit before granted a waiver. Please stay tuned for more information later today from both DHS and OAHHS on this matter.

In the meantime, a quick message from OAHHS:

  • Stay in communication with your local public health and emergency management system.
  • Think about what regulations you need waived and justification (waivers are site-specific and decided case-by-case).
  • Continue to make daily reports to the state on H1N1 incidence.

TRICARE CAH Reimbursement Final Rule

Archived 9/2/2011

The U.S. Department of Defense published a final payment rule on August 31, 2009, for critical access hospitals under TRICARE, which covers uniformed service members and their families. The rule is effective on December 1, 2009 and pays 101% of reasonable costs for inpatient and outpatient care. According to the rule, “ this rule implements the statutory provisions that TRICARE payment methods for institutional care be determined to the extent practicable in accordance with the same reimbursement rules as those that apply to payments to providers of services of the same type under Medicare. This final rule implements a reimbursement methodology similar to that furnished to Medicare beneficiaries for services provided by critical access hospitals (CAHs).”

Learn More

Medicare CY 2010 OPPS/ASC rule currently on display (CMS-1414-P)

Archived 9/2/2011

Medicare CY 2010 OPPS/ASC rule currently on display (CMS-1414-P) includes some proposed changes to current physician supervision requirements for outpatient services in hospitals and CAHs. Here follows an extract of the some relevant language included in the Fact Sheet for the proposed rule (also see information and links included further below):

Proposed Payment Provisions:

  • Physician supervision requirements – CMS is proposing to revise or further define several current policies for the physician supervision of outpatient services. First, CMS is proposing that nonphysician practitioners, specifically physician assistants, nurse practitioners, certified nurse specialists, and certified nurse-midwives, may directly supervise all hospital outpatient therapeutic services that they are able to personally perform within their state scope of practice and hospital-granted privileges. Under current policy, only physicians may provide the direct supervision of these services.

CMS Website on Recovery Act and Health Information Technology Now Available

Archived 9/2/2011

A new website from CMS now is available concerning Health Information Technology as provided for in the American Recovery and Reinvestment Act of 2009. On this website, you can find information pertaining to the Medicare and Medicaid incentives for electronic health records adoption and important links to related websites at the Department of Health and Human Services.

Posted now are:

  • A CMS fact sheet and questions/answers pertaining to the incentive programs
  • Link to press release pertaining to the process of defining meaningful use.
  • Resources on Health IT and privacy & security (HIPAA)

Bookmark CMS' page to find the latest on Health Information Technology.

Proposed DMEPOS Regulatory Updates

Archived 9/2/2011

CMS has announced limited proposed regulatory provisions for the Medicare durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) competitive bidding program. These proposals include a proposed administrative process for contract suppliers whose contracts were terminated by the Medicare Improvements for Patients and Providers Act of 2008 to submit claims for any applicable damages and proposed grandfathering provision updates. These proposed provisions are found in Section O of the Physician Fee Schedule and Other Revisions to Part B regulation (CMS-1413-P), which is now on display at the Office of the Federal Register.

Healthcare Common Procedure Coding System (HCPCS) Quarterly Update

Archived 9/2/2011

CMS is pleased to announce the scheduled release of modifications to the Healthcare Common Procedure Coding System (HCPCS) code set. These changes have been posted to the HCPCS website. Changes are effective on the date indicated on the update.

Revised National Correct Coding Initiative (NCCI) Edits for Physicians from July 1st

Archived 9/2/2011

Important Notice: If you downloaded the National Correct Coding Initiative (NCCI) Edits for Physicians (version number 15.2, effective 07/01/09 – 09/30/09) on July 6 or 7, 2009, please download the files again. Incorrect files were posted for the NCCI Edits for Physicians. The files have been corrected, and can be found on the CMS website.

Updated CAH Conditions of Participation

Archived 9/2/2011

The Conditions of Participation (CoP) for Critical Access Hospitals (State Operations Manual Appendix W) was updated on June 12, 2009. The addition includes § 485.610(e) Standard: Off-campus and Co-Location Requirements for CAHs.

The new version of Appendix W can be viewed online. Please note that Appendix W that was included in the Flex Coordinator Manual distributed April 2009 is now outdated.

This document was referenced in the July 21, 2009 Flex Webinar on CAH Surveys.

Upper Midwest Rural Health Research Center Policy Brief, June 2009

Archived 9/2/2011

Health Information Technology Policy and Rural Hospitals American Recovery and Reinvestment Act of 2009 (ARRA)

The Recovery Act appropriated $7.2 billion and directed the Department of Agriculture's Rural Utilities Service (RUS) and The Department of Commerce's National Telecommunications Information Administration (NTIA) to expand broadband access to unserved and underserved communities across the U.S., increase jobs, spur investments in technology and infrastructure, and provide long-term economic benefits.

The result is the RUS Broadband Initiatives Program (BIP) and the NTIA Broadband Technology Opportunities Program (BTOP).

Payment for Clinical Diagnostic Laboratory Tests Furnished by CAHs (page 24,202)

Archived 7/1/2009

The proposed policy on payment to CAHs for furnishing clinical diagnostic lab tests implements Medicare Improvements for Patients and Providers Act (MIPPA) section 148, which is effective for services furnished on or after July 1, 2009. As no doubt you know, MIPPA section 148 provides that patients in CAH owned and operated SNFs and clinics (including provider-based RHCs) are to be treated as CAH outpatients for purposes of reimbursing the CAH-performed lab tests which they receive: this means that the reimbursement for the lab tests must be made on a reasonable cost basis.

CMS proposes that in order for a CAH to receive 101 percent of reasonable costs for furnishing clinical diagnostic lab tests to such patients, the individual is not required to be physically present in the CAH at the time the specimen is collected but must continue to be an outpatient of the CAH and be receiving services directly from the CAH.

Under the proposal, if the individual is not physically present in the CAH at the time the specimen is collected, then in order to meet the requirement to be receiving services directly from the CAH either 1) the individual must receive other outpatient services in the CAH on the same day the specimen is collected or 2) the specimen must be collected by an employee of the CAH. The proposal also notes, however, that if the individual is physically present in the CAH or a facility that is provider-based to the CAH at the time of specimen collection (for example, in an RHC that is provider-based to the CAH), the CAH will receive payment for the lab tests at 101 percent of reasonable costs.

CAH Optional Method of Payment for Outpatient Services (page 24,203)

Archived 7/1/2009

CAHs which elect the optional method of reimbursement for outpatient services (often referred to as Method II), currently receive reimbursement at 101 percent of reasonable costs for outpatient facility service and reimbursement at 115 percent of the physician fee schedule amount for professional services.

CMS has noted, however, that the relevant statutory language, which states that a CAH which elects the optional method should be reimbursed (only) at reasonable costs for outpatient facility services, is inconsistent with the regulatory text which states that CAHs receive 101 percent of reasonable cost for these services. In order to ensure that the regulations are consistent with the plain reading of the statute, CMS proposes revising the regulations to state that CAHs which select the optional method of reimbursement will receive reasonable cost reimbursement (that is, 100 percent vs. 101 percent reasonable costs) for outpatient facility services. (This change will not affect the payment under Method II of the professional component.)

Provider-Based Status of Facilities and Organizations: Proposed Policy Changes (page 24,204)

Archived 7/1/2009

CMS proposes requiring that clinical diagnostic lab facilities that are part of CAHs must meet the provider-based rules. Currently, Medicare provider-based regulations provide that clinical diagnostic lab facilities are exempt from provider-based determinations, as lab services furnished in such facilities generally are reimbursed under the Medicare clinical lab fee schedule and the reimbursement for the lab services do not change if these facilities are free-standing or part of a hospital.

As we know, however, clinical diagnostic lab tests performed in CAHs are paid at 101 percent of reasonable cost (not under the lab fee schedule), so that there is a payment differential for lab tests performed in clinical diagnostic lab facilities that are part of a CAH. Therefore, CMS believes the clinical diagnostic laboratory facilities indeed must meet the provider-based rules if they are part of a CAH and wish to have the lab tests they perform reimbursed at the CAH payment rate of 101 percent of reasonable cost.

This proposal would affect the Medicare provider-based regulations at 413.65(a)(1)(ii)(G), which currently states CMS does not make provider based determinations for “Independent diagnostic testing facilities furnishing only services paid under a fee schedule, such as facilities that furnish only screening mammography services (as defined in section 1861(jj) of the Act), facilities that furnish only clinical diagnostic laboratory tests, or facilities that furnish only some combination of these services.” The Medicare provider-based regulations would be revised to provide for provider-based determinations of facilities which furnish only clinical diagnostic laboratory tests when they are operated by a CAH.

Within this same Preamble section, CMS also mentions CAH-based ambulances and solicits public comments concerning whether an ambulance which is CAH owned and operated and eligible to receive reasonable cost-based payments (i.e., because there is no other supplier of ambulance services located within 35 miles of the CAH ambulance shed) should be required to also meet the Medicare provider-based requirements.