SPECIAL ALERT!
CMS Survey Manual Has Incorrect Co-Signature Requirements!
The Centers for Medicare and Medicare Services (CMS) has failed to include two crucial regulatory paragraphs in its survey manual for Critical Access Hospitals (CAH). The State Operations Manual (SOM), also known as the "Interpretive Guidelines," is written by CMS to guide its hospital surveyors.
The language in the online manual dated June 12, 2009, incorrectly implies a 100 percent physician co-signature requirement on inpatient and outpatient charts. The two missing paragraphs provide much more flexibility with respect to physician cosignature on outpatients records. (The regulations also apply to nurse practitioners, clinical nurse specialists, and certified nurse-midwives).
CMS staff has acknowledged the error in the online manual, but declined to correct it at this time. An email response from CMS states:
From: DeMichele, Kimberly (CMS/CMSO)
[mailto:
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
]
Sent: Tuesday, September 22, 2009 9:55 AM
To: Ellen Rathfon (PC)
Subject: RE: CAH mid-level practitioner co-signature requirements
Dear Ellen,
It was a pleasure speaking to you last month.
We are aware of the missing regulatory text at C-0260 in the
State Operations Manual (SOM). Fortunately, the regulation
is correctly worded in ASPEN, the electronic survey support
system that the surveyors use in the field. Given this
and current resource constraints, we are unable to address
the issue at this time. However, a major revision of the SOM
(Appendix W, Critical Access Hospitals) is planned for
early next calendar year and the correction will be made
at that time.
Kim
Kimberly DeMichele
CMSO/SCG/DACS
(410) 786-4286
The information provided in this email is intended only to be general summary
information to the public. It is not intended to take the place of statute,
regulations, or official CMS policy.
The correct, current federal regulations regarding chart co-signature, on which the surveyors guide is based, state:
Medicare Conditions of Participation for hospitals
Code of Federal Regulations, Title 42 Section 485.631
(b) Standard: Responsibilities of the doctor of medicine or osteopathy.
(1) The doctor of medicine or osteopathy-
(i) Provides medical direction for the CAH's health care activities and
consultation for, and medical supervision of, the health care staff;
(ii) In conjunction with the physician assistant and/or nurse practitioner
member(s), participates in developing, executing, and periodically
reviewing the CAH's written policies governing the services it furnishes.
(iii) In conjunction with the physician assistant and/or nurse practitioner
members, periodically reviews the CAH's patient records, provides
medical orders, and provides medical care services to the patients
of the CAH; and
(iv) Periodically reviews and signs the records of all inpatients cared
for by nurse practitioners, clinical nurse specialists, certified nurse
midwives, or physician assistants.
(v) Periodically, but not less than every 2 weeks, reviews and signs a
sample of outpatient records of patients cared for by nurse practitioners,
clinical nurse specialists, certified nurse midwives, or physician assistants
according to the policies of the CAH and according to current standards
of practice where State law requires record reviews or co-signatures, or
both, by a collaborating physician.
(vi) Is not required to review and sign outpatient records of patients cared
for by nurse practitioners, clinical nurse specialists, certified nurse midwives,
or physician assistants where State law does not require record reviews
or cosignatures, or both, by a collaborating physician.
The final two paragraphs (v and vi) and the addition of certified nurse midwives to paragraph (iv), were published as final regulations on November 10, 2005, and took effect on January 1, 2006. The June 2009 edition is the first complete update of the surveyor manual since May 2004, and CMS failed to include the 2006 regulatory language in its updated online manual.
The 2009 manual that is available to the public incorrectly states that physicians must "review and sign all medical records for patients care for by mid-level practitioners at the CAH." According to CMS staff, the password-protected online ASPEN system used by surveyors is correct.
If questions arise, please refer to this AAPA web page and to current federal regulations, which can be found at this link. http://edocket.access.gpo.gov/cfr_2008/octqtr/pdf/42cfr485.631.pdf
For further information about this issue or other issues related to physician assistant practice in Critical Access Hospitals, contact Ellen Rathfon in the AAPA professional affairs office, This e-mail address is being protected from spambots. You need JavaScript enabled to view it or 703-836-2272, ext. 3210.
