CMS SOM App. A, Tag A-0339

Staff

The medical staff must be composed of doctors of medicine or osteopathy. In accordance

with State law, including scope-of-practice laws, the medical staff may also include other

categories of physicians (as listed at §482.12(c)(1)) and non-physician practitioners who are

determined to be eligible for appointment by the governing body.

Interpretive Guidelines §482.22(a)

The hospital’s governing body has the responsibility, consistent with State law, including scope-of-practice laws, to determine which types/categories of physicians and, if it so chooses, non-physician practitioners or other licensed healthcare professionals (collectively referred to in this

guidance as “practitioners”) may be privileged to provide care to hospital patients. All

practitioners who require privileges in order to furnish care to hospital patients must be evaluated

under the hospital’s medical staff privileging system before the hospital’s governing body may

grant them privileges. All practitioners granted medical staff privileges must function under the

bylaws, regulations and rules of the hospital’s medical staff. The privileges granted to an

individual practitioner must be consistent with State scope-of-practice laws.

Physicians:

The medical staff must at a minimum be composed of doctors of medicine or doctors of

osteopathy. In addition, the medical staff may include other types of practitioners included in the

definition in Section 1861(r) of the Social Security Act of a “physician:”

• Doctor of dental surgery or of dental medicine;

• Doctor of podiatric medicine;

• Doctor of optometry; and a

• Chiropractor.

In all cases, the practitioner included in the definition of a physician must be legally authorized

to practice within the State where the hospital is located and providing services within their

authorized scope of practice. In addition, in certain instances the Social Security Act and

regulations attach further limitations as to the type of hospital services for which a practitioner

may be considered to be a “physician.” See §482.12(c)(1) for more detail on these limitations.

The governing body has the flexibility to determine, consistent with State law, whether

practitioners included in the definition of a physician, other than doctors of medicine or

osteopathy, are eligible for appointment to the medical staff.

For Information Only – Not Required/ Not to be Cited

CMS expects that all physician practitioners granted privileges are also appointed as members

of the medical staff. However, if State law limits the composition of the hospital’s medical

staff to certain categories of practitioners, e.g., only MDs or DOs, there is nothing in the CoPs

that prohibits hospitals and their medical staffs from establishing certain practice privileges for

other categories of physician practitioners excluded from medical staff membership under

State law, or from granting those privileges to individual practitioners in those categories, as

long as such privileges are recommended by the medical staff, approved by the governing

body, and in accordance with State law. (79 FR 27114 - 27115, May 12, 2014)

For physician practitioners granted privileges only, , the hospital’s governing body and its

medical staff must exercise oversight, such as through credentialing and competency review, of

those other physician practitioners to whom it grants privileges, just as it would for those

practitioners appointed to its medical staff.

Non-physician practitioners

Furthermore, the governing body has the authority, in accordance with State law, to grant

medical staff privileges and membership to non-physician practitioners. The regulation allows

hospitals and their medical staffs to take advantage of the expertise and skills of all types of

practitioners who practice at the hospital when making recommendations and decisions

concerning medical staff privileges and membership.

For Information Only – Not Required/ Not to be Cited

CMS expects that all practitioners granted privileges are also appointed as members of the

medical staff. However, if State law limits the composition of the hospital’s medical staff to

certain categories of practitioners, e.g., only physician practitioners, there is nothing in the

CoPs that prohibits hospitals and their medical staffs from establishing certain practice

privileges for those specific categories of non-physician practitioners excluded from medical

staff membership under State law, or from granting those privileges to individual practitioners

in those categories, as long as such privileges are recommended by the medical staff, approved

by the governing body, and in accordance with State law. (79 FR 27114 - 27115, May 12,

2014)

For non-physician practitioners granted privileges only, the hospital’s governing body and its

medical staff must exercise oversight, such as through credentialing and competency review, of

those non-physician practitioners to whom it grants privileges, just as it would for those

practitioners appointed to its medical staff.

Practitioners are described in Section 1842(b)(18)(C) of the Act as any of the following:

• Physician assistant (as defined in Section 1861(aa)(5) of the Act);

• Nurse practitioner (as defined in Section 1861(aa)(5) of the Act);

• Clinical nurse specialist (as defined in Section 1861(aa)(5) of the Act);

• Certified registered nurse anesthetist (as defined in Section 1861(bb)(2) of

the Act);

• Certified nurse-midwife (as defined in Section 1861(gg)(2) of the Act);

• Clinical social worker (as defined in Section 1861(hh)(1) of the Act);

• Clinical psychologist (as defined in 42 CFR 410.71 for purposes of Section

1861(ii) of the Act);

• Anesthesiologist’s Assistant (as defined in §410.69); or

• Registered dietician or nutrition professional.

Other types of licensed healthcare professionals have a more limited scope of practice and

usually are not eligible for hospital medical staff privileges, unless their permitted scope of

practice in their State makes them more comparable to the above types of non-physician

practitioners. Some examples of types of such licensed healthcare professionals who might be

eligible for medical staff privileges depending on State law and medical staff bylaws, rules and

regulations include, but are not limited to:

• Physical Therapist (as defined at §410.60 and §484.4);

• Occupational Therapist (as defined at §410.59 and §484.4); and

• Speech Language Therapist (as defined at §410.62 and §484.4).

Furthermore, some States have established a scope of practice for certain licensed pharmacists

who are permitted to provide patient care services that make them more like the above types of

non-physician practitioners, including the monitoring and assessing of patients and ordering

medications and laboratory tests. In such States, a hospital may grant medical staff privileges to

such pharmacists and/or appoint them as members of the medical staff. There is no standard

term for such pharmacists, although they are sometimes referred to as “clinical pharmacists.”

Practitioners may be granted active, courtesy, emergency, temporary, etc. membership or

privileges in accordance with state law and as specified in the medical staff bylaws, rules, and

regulations.

Survey Procedures §482.22(a)

• Ask the hospital and medical staff leadership to describe the categories of

practitioners who are members of the medical staff or who may be granted medical

staff privileges. Ask for documentation that supports their response.

• If the hospital grants medical staff privileges and/or membership to physicians who

are not MDs/DOs or to non-physician practitioners, ask the hospital and medical staff

leadership to describe the process the hospital uses to ensure that any privileges

granted are consistent with State law. Ask for documentation that supports their

response.

Ask the hospital and medical staff leadership to describe the process by which they exercise

oversight of practitioners granted privileges only.