CMS SOM App. A, Tag A-1080

Outpatient services must be ordered by a practitioner who meets the

following conditions:

(1) Is responsible for the care of the patient.

(2) Is licensed in the State where he or she provides care to the patient.

(3) Is acting within his or her scope of practice under State law.

(4) Is authorized in accordance with State law and policies adopted by the medical

staff, and approved by the governing body, to order the applicable outpatient

services.

This applies to the following:

(i) All practitioners who are appointed to the hospital’s medical staff and

who have been granted privileges to order the applicable outpatient services.

(ii) All practitioners not appointed to the medical staff, but who satisfy the

above criteria for authorization by the medical staff and the hospital for ordering

the applicable outpatient services for their patients.

Interpretive Guidelines §482.54(c)

Orders for outpatient services may be made by any practitioner who is:

• Responsible for the care of the patient;

• Licensed in, or holds a license recognized in, the jurisdiction where he/she

provides care to 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 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.

This regulation allows hospitals to accept orders for outpatient services both from

practitioners who hold hospital privileges as well as practitioners who do not, including

those who are not located in the hospital’s close geographic area.

It is not uncommon for individuals to obtain health care services in a variety of locations

from a variety of practitioners. Sometimes an individual elects to seek services from a

specialist in a tertiary setting removed from the area where the individual lives, but

prefers to get follow-up care, such as physical therapy after a surgery, closer to home.

Sometimes an individual may have multiple residences in different areas and may need to

continue care locally when moving between residences. Sometimes individuals receive

urgent or even emergent care while traveling. Accepting orders and referrals for

outpatient services from practitioners not on the medical staff or not holding privileges

enables a hospital to promotes ready access to care for patients in the area it serves.

Finally, sometimes a practitioner who does not practice in a local hospital may

nevertheless refer patients to that hospital for outpatient services, such as diagnostic

imaging, physical and occupational therapy, etc.

The authority to write orders for outpatient services is covered under the hospital’s

medical staff privileging process for members of the hospital’s medical staff and for

practitioners who have been granted privileges by the hospital without being appointment

to the medical staff.

For practitioners who do not hold hospital privileges the hospital’s medical staff policy

may permit them to refer patients to the hospital with orders for specific outpatient

services so long as all of the above criteria are met. The policy must address how the

hospital verifies the referring/ordering practitioner is appropriately licensed and acting

within his/her scope of practice. The regulation does not prescribe the details of the

licensure and scope of practice verification process but instead provides a hospital the

flexibility to accomplish this in the manner it finds efficient and effective. The hospital is

expected to ensure the verification process is followed for all outpatient services in all

hospital locations.

The policy must also make clear whether the policy applies to all hospital outpatient

services, or whether there are specific services for which orders may only be accepted

from practitioners with medical staff privileges. For example, a hospital may prefer not

to accept orders for a regimen of outpatient chemotherapy or outpatient therapeutic

nuclear medicine services from a referring physician who does not hold medical staff

privileges. In such cases, the hospital’s policy must make these exceptions clear to the

general authorization for accepting orders from referring practitioners.

Survey Procedures §482.54(c)

Survey a variety of settings that offer outpatient services. Ask department

staff whether orders or referrals for that type of outpatient service are

accepted from practitioners who do not hold hospital privileges. If yes:

• Ask for evidence that the medical staff has adopted the policy.

• Ask how the hospital verifies that the order or referral comes from a

referring practitioner who is appropriately licensed in the jurisdiction

where he/she provides care to the patient and is practicing within

his/her scope of practice under State law to prescribe such orders. Ask

for documentation of such verification efforts.

• Ensure the same verification process is followed consistently in all outpatient

settings.