CMS SOM App. G, Tag J-0122

(2) The clinic . . . is primarily engaged in providing outpatient health services and

meets all other conditions of the subpart.

(c) Direct services – (1) General. The clinic…staff furnishes those diagnostic and

therapeutic services and supplies that are commonly furnished in a physician's

office or at the entry point into the health care delivery system. These include

medical history, physical examination, assessment of health status, and treatment

for a variety of medical conditions

§ 491.2 Definitions. As used in this subpart, unless the context indicates

otherwise:

Direct services mean services provided by the clinic’s staff.

Interpretative Guidelines § 491.9(a)(2) & (c)(1)

An RHC is required to be primarily engaged in providing outpatient or ambulatory health

care services. In accordance with §§ 405.2411 - 2416, RHC services include the services

of physicians, NPs, PAs, certified nurse midwives, clinical psychologists and clinical

social workers, along with the services and supplies that are incident to these

practitioners’ services. In accordance with § 491.9(c)(1), the services of these

practitioners are those commonly furnished in a physician’s office or at the entry point

into the health care delivery system. These services include taking complete medical

histories, performing complete physical examinations, assessments of health status,

routine lab tests, diagnosis and treatment for common acute and chronic health problems

and medical conditions, immunization programs and family planning.

Further, some RHCs may provide VNS if a request is submitted to the SA and approved

by the CMS RO.

RHCs are not prohibited from furnishing other services, for example, ambulatory surgical

procedures or diagnostic imaging services. However, they may not be primarily engaged

in providing such specialized services. In the context of an RHC, “primarily engaged” is

determined by considering the total hours of an RHC’s operation, and whether a majority,

i.e., more than 50 percent, of those hours involve provision of RHC services.

An example of a clinic schedule that combines RHC with other services would be a clinic

that provides RHC services 9 a.m. to 4 p.m. Monday through Friday, and also offers

diagnostic imaging services Tuesday and Friday afternoons from 1 p.m. to 4 p.m. The

RHC is furnishing 35 hours of standard RHC services and 6 hours of imaging services,

for a total of 41 hours of service. In this example, the RHC provides RHC services 85

percent of the time; therefore, it is “primarily engaged” in providing RHC services.

For clinics with a limited schedule, it may be more appropriate to consider the monthly

total operating schedule verses the weekly schedule.

Survey Procedures § 491.9(a)(2) & (c)(1)

• Review the clinic’s website, and ask the clinic director to describe the types of

services the clinic offers. Does it include specialty services that are not RHC

services? If yes:

• Review the hours the specialty services are available and the hours RHC services are

available, to determine whether the majority of time the RHC provides RHC services.

• Review a sample of patient health records covering at least the two previous months

to determine the majority of specific services actually furnished.