CMS SOM App. L, Tag Q-0121

Members of the medical staff must be legally and professionally qualified for the

positions to which they are appointed and for the performance of privileges granted.

The ASC grants privileges in accordance with recommendations from qualified

medical personnel.

Interpretive Guidelines §416.45(a)

All members of the ASC’s medical staff and all clinicians granted medical staff

privileges must be appointed to their position within the ASC by the ASC’s governing

body. They must be granted privileges by the governing body, in writing, that specify in

detail the types of procedures they may perform within the ASC. It is not sufficient for

the governing body to grant privileges to “perform surgery” or even to perform

“orthopedic surgery.” For example, an ASC that specializes in orthopedic surgery of

various types must specify which types of procedures each surgeon is privileged to

perform.

The ASC’s governing body must assure that medical staff privileges are granted only to

legally and professionally qualified practitioners.

“Legally qualified” means the practitioner has a current license to practice within the

State where the ASC is located, and that the privileges to be granted fall within that

State’s permitted scope of practice. The ASC must verify that each practitioner has a

current professional license and document the license in the practitioner’s file.

“Professionally qualified” means that the practitioner has demonstrated competence in

the area for which privileges are sought. Competence is demonstrated through evidence

of specialized training and experience, e.g., certification by a nationally recognized

professional board.

The governing body is also required to solicit the opinion of qualified medical personnel

on the competence of applicants for privileges. The recommendation provided must be in

writing, and should include a supporting rationale. The qualified medical personnel may

be current members of the ASC’s medical staff, but may also be physicians not practicing

in the ASC. ASCs should consider seeking the recommendations of qualified outside

physicians when they do not have appropriate expertise in-house to evaluate the

competency of an applicant for privileges. This is particularly advisable when the ASC’s

governing body consists of one physician owner who is also the sole member of the

medical staff. The ASC’s governing body is not required to accept the recommendation

provided by the qualified medical personnel to grant, deny, or restrict privileges to a

practitioner. However, when the ASC’s governing body makes a decision contrary to the

recommendation, it is expected to document its rationale for doing so.

The ASC should document the process by which the governing body grants medical staff

privileges, including the documentation, or credentials, it reviews for each candidate, the

criteria it uses in evaluating the candidate, how it selects the qualified medical personnel

who make recommendations on the practitioner’s qualifications, and whether and under

what circumstances the governing body may make a privileging decision contrary to the

recommendation of the qualified medical staff.

Survey Procedures: §416.45(a)

• Ask the ASC’s leadership to explain its process for granting clinical privileges.

• Review a sample of files to verify medical staff have been granted clinical

privileges.

There must at a minimum be documentation of:

o State licensure, registration, or state certification, as applicable;

o Certification by a specialty organization, as appropriate;

o Other training or pertinent experience;

o Evidence of a recommendation by qualified medical personnel

concerning the practitioner’s competence;

o The scope of the privileges granted to the practitioner; and

o If the governing body granted privileges against the recommendation

of the qualified medical personnel, its rationale for doing so.

• Does the review of each practitioner’s record provide evidence that they are

legally and professionally qualified to exercise the privileges granted them by the

ASC?