The Centers for Medicare & Medicaid Services (“CMS”), in the March 8, 2013 Memorandum, issued new guidance specifying those tasks that can and cannot be delegated in skilled nursing facilities (“SNFs”) and nursing facilities (“NFs”). Physicians who improperly assign tasks to non-physician practitioners (“NPPs”) jeopardize the SNFs’ and NFs’ compliance with federal and state regulations, which potentially affects the facilities’ reimbursement.
Because care in SNFs is paid by Medicare Part A and care in NFs is paid by Medicaid, the setting is a key element in determining the delegation of tasks to NPPs. Set forth below are delegation summaries of the regulations and statutes for both SNFs and NFs.
Skilled Nursing Facilities:
Under 42 C.F.R. § 483.40(c)(3), all required physician visits must be made by the physician only. Required visits include the initial comprehensive visit and alternate visits. Pursuant to 42 C.F.R. § 483.40(c)(4), during the initial comprehensive visit, which must be completed no later than 30 days after the resident’s admission, the physician must: (1) complete a thorough assessment of the resident; (2) develop a plan of care; and (3) write or verify the admission order. The physician can then delegate alternate visits to state-licensed NPPs who perform tasks within the scope of practice permitted under 42 C.F.R. §§ 483.40(c)(4). Documentation of these alternate visits can also be signed by the NPP without the physician’s co-signature. An NPP who is not employed by an SNF is permitted to perform the initial certification and recertification to verify a resident meets the requirements for daily skilled nursing care or rehabilitation services.
Nursing Facilities:
Unlike in SNFs, NPPs are permitted to perform the initial comprehensive visit if they are not employed by the NF, are working in collaboration with a physician and if permitted by state law. NPPs are also allowed to perform other medically necessary services. In some states, an NPP who is an employee of the facility is allowed to perform a medically necessary visit for a resident’s complaint and to write an order for treatment (i.e., a headache). If an NPP is permitted to perform a medically necessary visit, they are allowed to write an applicable order for that visit without a physician’s co-signature unless prohibited by state law.
Dually-Certified Facilities:
In dually-certified facilities, the facility must determine if a resident’s stay is being paid for by Medicare Part A or Medicaid and apply the applicable requirements set forth above for SNFs and NFs.
The Memorandum and a quick reference guide of the provisions can be accessed here.
If you have questions or concerns regarding the foregoing or would like additional information, please contact Todd Selby at tselby@wp.hallrender.com or 317.977.1440, Brian Jent at bjent@wp.hallrender.com or 317.977.1402, David Bufford at dbufford@wp.hallrender.com or 502.568.9368 or your regular Hall Render attorney.
