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As we’ve discussed previously, the Centers for Medicare and Medicaid Services (CMS) reclassified all services in the Hospital-Based Outpatient Department (HOPD) under “general supervision” away from “direct supervision,” with the caveat that it was up to the facilities and practitioners which services ought to remain under “direct” supervision.

In the past, a physician had to be physically present in the HOPD for ANY service to be rendered, even if he or she did not go into the room with the patient. Services like compression bandaging could be provided under “general” supervision (which is what we often call a “nurse only” visit). To be clear, because ALL services in the HOPD are provided “incident to” the physician, a supervising physician MUST be designated – even if he or she is providing “general” supervision remotely. While general supervision does not require the doctor to be physically present, the doctor is still legally and medically liable for the care provided, even if they are not physically there. (Ponder that in your mind with regard to HBOT.)

I posted a list of the questions that I asked my Novitas Medical Director about “general” vs. “direct” physician supervision with regard to supervising hyperbaric oxygen therapy (HBOT).

Leaving aside the question of whether I SHOULD provide HBOT under “general” supervision, since I am medically and legally responsible for what happens regardless of whether I am on site, I asked if it was possible to bill for supervising HBOT even if I am not physically there? (I would not personally do that, but I wanted to know the answer.) I haven’t gotten an answer from CMS or Novitas, but here’s what I would do if I was CMS. I’d create two different payment rates for HBOT supervision, one for direct (physically being there – the payment we have now) and one for “general” (“remote” supervision). Then I’d see how often each code gets used (I’d see how often doctors are supervising HBOT remotely), and then I’d eventually stop paying for direct supervision, arguing that remote supervision seems to work just fine…  That seems where this is going to me, but I don’t have any inside knowledge.

Funnily enough, we went through this with HBOT once before, in a manner of speaking. Two decades ago, there were a lot of facilities charging for HBOT treatments without a doctor present. It was one of the issues reviewed by the Office of the Inspector General (OIG) when they evaluated hyperbaric oxygen therapy services. There is a LOT more to this story which can probably be told now (two decades later), but for the moment, I’m focused on general vs. direct supervision of HBOT. I thought I’d post this comment by Dr. Tom Bozzuto, who has as much grey hair as I do (but you still look GOOD, Tom…)

In 1999, I was one of 4 physicians selected by the HHS (Health and Human Services) OIG to review charts from every hospital billing for HBOT. My comments on changing direct supervision to general are listed below. I sent this letter to CMS after it was recently decided the supervision requirement would be changed. The OIG review is 22 years old, but evidently CMS does not learn from its past mistakes. At the end of the document, HHS outlined recommendations to (then) the Healthcare Finance Administration (HCFA)- which became CMS. None of the OIG’s recommendations were implemented.

In 1999, HHS OIG initiated a review, “Hyperbaric Oxygen Therapy: Its Use and Appropriateness”. I had the privilege of being one of the four physician reviewers for this investigation. This review included all hyperbaric facilities that were billing Medicare for 99183.

In the summary (page ii) their conclusion was “…our medical reviewers determined that more than 25% of beneficiaries had no documented physician oversight of their treatments; and almost twice that many (44%) did not have a physician in attendance at their treatments.  …our medical review showed a correlation between certain quality of care factors and physician attendance.

The summary also stated that:

  • $14.2 million was paid in error for hyperbaric treatments
  • $4.9 million was paid for treatments deemed to be excessive
  • 37% of beneficiaries received questionable quality of care with respect to either lack of appropriate testing prior to initiation of treatment, or insufficient progress documented to justify continuation of treatment.
  • The treatments with suspect quality account for as much as $11.1 million in payments (2 decades ago).

The OIG states (on page 12): Over 75% of medical directors agree that physician attendance is necessary to promote either safety, quality of care, or both. Similarly, our medical review results supported this concept, showing a significant relationship (p<.001) between quality of care variables and physician attendance and between compliance with HCFA guidelines and physician attendance (p<.001). For example, 74% of the payments deemed “inappropriate” by our reviewers did not appear to have a physician in attendance. We cannot be certain that physician attendance would have corrected all of these payments, but the strong relationship between quality and attendance suggests a potential for reducing inappropriate payments. The reviewers determined that more than 25% of the beneficiaries had no physician oversight of their treatments and twice that many (44%) did not have physician attendance at their treatments.

On Page 18, there is comment about the American College of Hyperbaric Medicine’s document, “Physicians’ Duties in Hyperbaric Medicine” clearly delineating the work required to properly supervise a hyperbaric patient before, during, and after their hyperbaric oxygen therapy – duties that would be impossible for a physician to comply with were they not in attendance during the therapy.

It is clear from this report, over two decades ago, that physician attendance via direct supervision:

  • Improves quality of care
  • Results in less inappropriate treatment
  • Results in less inappropriate billing (both for inappropriate conditions or for excessive treatments
  • Results in significant cost savings to Medicare

Thomas M. Bozzuto, DO, FACEP, FFACHM, UHM/ABEM, FAPWCAc
I Medical Director I Phoebe Wound Care and Hyperbaric Center
O: 229-312-7600 I F: 229-312-7620 I E: tbozzuto@phoebehealth.com
803 N. Jefferson St., Suite A  I  Albany, Georgia 31701 I  www.phoebehealth.com

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