CMS SOM App. L, Tag Q-0123

If the ASC assigns patient care responsibilities to practitioners other than

physicians, it must have established policies and procedures, approved by the

governing body, for overseeing and evaluating their clinical activities.

Interpretive Guidelines: §416.45(c)

Patient care responsibilities (which may or may not include formal medical staff

privileges, but excluding nursing care services) may be assigned to licensed practitioners

not meeting the definition of physician in §1861(r) of the Act. “Physician” is defined in

§1861(r)

of the Social Security Act as:

• Doctor of medicine or osteopathy;

• Doctor of dental surgery or of dental medicine;

• Doctor of podiatric medicine;

• Doctor of optometry with respect to services legally authorized to be performed in

the State; and

• Chiropractor with respect to treatment by manual manipulation of the spine (to

correct subluxation diagnosed by x-ray).

When an ASC uses licensed practitioners to provide patient care, other than nursing care,

the ASC’s governing body must approve written policies and procedures that establish a

system for overseeing and evaluating the quality of the clinical services provided by other

practitioners. The policies must address:

• The specific types of clinical activities that each class of practitioner, e.g., Nurse

Practitioner, Physician’s Assistant, CRNA, will be eligible to perform. The ASC

may not permit performance of any activities that are outside the licensed

practitioner’s permitted scope of practice under applicable State law;

• The process by which the ASC exercises oversight over each class of practitioner.

Depending on the practitioner’s scope of practice, physician supervision of the

practitioner may be required; in other cases oversight through collaborative

practice with a physician or some other means may suffice;

• The process and criteria for reviewing the qualifications of each individual

practitioner before he/she is permitted to provide patient care; and

• The process, criteria and frequency for evaluating the performance in providing

clinical services by practitioners other than physicians. Evaluations must take

place at regular intervals specified in the ASC’s policy.

Survey Procedures: §416.45(c)

• Determine whether the ASC uses licensed practitioners other than physicians to

provide care, other than nursing care, within the ASC. If it does:

• Ask to see the ASC’s policy governing the oversight and evaluation of

practitioners other than physicians. Does the policy address all required

issues?

• Review the personnel files for each licensed practitioner who is not a

physician providing patient care in the ASC. Does each file contain evidence

of the practitioner’s qualifications, consistent with the ASC’s policy? Does

each file contain evidence of periodic evaluation of the practitioner’s

performance?