CMS SOM App. G, Tag J-0100

The physician performs the

following:

(1) . . . provides medical direction for the clinic's . . . health care activities and

consultation for, and medical supervision of, the health care staff.

(3) . . . provides medical orders, and provides medical care services to the patients

of the clinic or center.

Interpretative Guidelines § 491.8(b)(1) & (3)

In accordance with § 491.8(b), the MD or DO physician who serves as the RHC’s

medical director in accordance with § 491.7(a)(1) is responsible for the overall medical

direction of the clinic’s clinical activities. He or she also provides clinical consultation to

and supervises the other physician(s) as well as the non-physician practitioners on the

RHC’s health care staff. This requirement for “supervision” does not limit the ability of

non-physician practitioners to practice in accordance with their State scope of practice.

For example, if State law permits an NP to practice independently when providing

diagnosis and treatment, including writing orders and prescriptions, the NP would be

permitted to do so in the RHC as well. However, the NP, like any other member of the

clinic’s staff of health care practitioners, would be under the overall medical supervision

of the clinic’s medical director, who is responsible for the quality of care in the clinic.

In addition to medical direction as described above, the physician must provide

assessment, diagnosis, and treatment of patients, and provide medical orders for patients

in need of diagnostic tests and/or therapeutic treatments.

If the clinic has more than one physician on its staff, the other physician(s) may also

provide medical services, medical orders, and consultation, but only one physician, who

must be an MD or DO, can serve as the clinic’s medical director and provide overall

direction to its clinical activities.

NOTE: To ensure continuity of care, it is permissible to use a locum tenens (i.e.,

temporary) MD/DO as the medical director of the RHC, providing that same MD/DO is

contractually bound to provide services to the clinic for a minimum of six months.

A physician is not required to be on-site in order to perform all of these duties, unless

there are times during the RHC’s operating hours when no other physician, NP, CNM,

PA, clinical social worker or clinical psychologist is present in the RHC. With the

development of technology that facilitates telemedicine, a physician has the flexibility to

use a variety of ways and timeframes to provide medical direction, consultation,

supervision, clinical record review, including being on-site at the facility to provide

medical care services to patients. The regulation allows for use of team-based care while

still requiring the physician to be on-site, as appropriate based on the needs of the clinic,

to ensure the delivery of quality care. A State or the RHC itself is not precluded from

establishing requirements for physician on-site presence that are more stringent, but these

requirements are not enforced through the Federal Medicare certification process.

Survey Procedures § 491.8(b)(1) & (3)

• Ask the clinic’s medical director how he or she provides overall medical direction

and supervision for the clinic.

• Review a sample of pertinent clinic records. Is there evidence in the sample of

clinical records reviewed that a physician provided assessment, diagnosis, or

treatment services and/or wrote orders for patient testing and/or care?