Requirements For Ordering Hospital Outpatient Services Clarified By CMS


A Health Care E-Alert

The Centers for Medicare and Medicaid Services ("CMS") provided clarification regarding the Hospital Condition of Participation ("CoP") governing outpatient services (42 C.F.R. 482.54) in a Memorandum to State Survey Agency Directors dated February 17, 2012. As set forth in this guidance, CMS interprets the outpatient services CoP (which is silent on the issue of who may order such services) to mean that 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 hospital’s 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.

According to CMS, the policy 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. Additionally, the policy must specify whether it applies to all hospital outpatient services or whether there are specific services for which orders may only be accepted from practitioners with privileges at the hospital. The policy must make clear any exceptions to the general authorization for referring practitioners.

Thus, it is not prohibited for a hospital to accept an order for outpatient services from a practitioner who does not have clinical privileges at the hospital. The new guidance applies to all outpatient services and expressly supersedes the guidance in Transmittal 72 issued November 18, 2011, that stated that a practitioner must have privileges at the hospital to write orders for rehabilitation and respiratory care services.

Hospitals should check their current policies regarding outpatient orders/referrals to ensure compliance with the latest CMS guidance.

This E-Mail Alert was prepared by Kimberly Parks. Please contact any member of the Bricker & Eckler Health Care Group for more information.

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