CMS SOM App. W, Tag C-0986

[The doctor of medicine or osteopathy-]

(iv) Periodically reviews and signs the records of all inpatients cared for by nurse

practitioners, clinical nurse specialists, or physician assistants.

(v) Periodically reviews and signs a sample of outpatient records of patients cared

for by nurse practitioners, clinical nurse specialists, certified nurse midwives, or

physician assistants only to the extent required under State law where State law

requires record reviews or co-signatures, or both, by a collaborating physician.

Interpretive Guidelines §485.631(b)(1)(iv) & (v)

All inpatient records for patients whose treatment is/was managed by a nonphysician

practitioner in the CAH, i.e., nurse practitioners, clinical nurse specialists, or physician

assistants, must be reviewed periodically by a CAH MD/DO who must sign the records

after the review has been completed. The MD/DO review is expected to cover all

applicable inpatient records open at the time of the review, as well as all applicable

inpatient records closed since the last review.

In the case of inpatients whose care is/was managed by an MD/DO, as evidenced by an

admission order, progress notes, and/or medical orders, etc., but who also receive

services from a non-physician practitioner, a subsequent MD/DO review of the inpatient

record is not required.

In States where State law requires a collaborating physician to review medical records,

co-sign medical records, or both for outpatients whose care is managed by a non-physician practitioner, i.e., a nurse practitioner, a clinical nurse specialist, a certified

nurse midwife, or a physician assistant, a CAH MD/DO must review and sign a sample

of outpatient records. The outpatient medical record sample reviewed must be

representative of all non-physician practitioners providing care to patients of the CAH.

The CAH determines by policy the size of the sample reviewed and signed; however,

CMS recommends, but does not require, a sample size of 25% of the records of all

outpatient encounters managed by a non-physician practitioner since the prior MD/DO

review. If State law requires MD/DO review or signature of a larger percentage of the

outpatient records, the CAH must comply with State law.

In States where no physician record review or physician co-signature is required for

patients managed by a non-physician practitioner, an MD/DO is not required to review or

sign outpatient records of such patients.

Neither the regulation nor the preamble to the final rule adopting this regulation (79 Fed.

Reg. 27105, May 12, 2014) specify a particular timeframe to satisfy the requirement for

“periodic” review, but the CAH must specify a maximum interval between inpatient

record reviews in its policies and procedures. The CAH is expected to take into account

the volume and types of services it offers in developing its policy. For example, a CAH

that has only four certified beds and one MD/DO on staff and which does not always

have an inpatient in house would likely establish a different requirement for inpatient

record review than a CAH with 25 certified beds, multiple MDs/DOs on staff and a high

inpatient occupancy rate. Further, there is no regulatory requirement for the review of

records to be performed on site and in person. Thus, if the CAH has electronic medical

records that can be accessed and digitally signed remotely by the MD or DO, this method

of review is acceptable. Therefore, CAHs with and without the capability for electronic

record review and signature might also develop different policies for the maximum

interval between reviews.

Survey Procedures §485.631(b)(1)(iv) & (v)

Select a sample of inpatient and outpatient records, including both open and closed

records.

• For inpatient records of patients whose care is/was managed by a non-physician

practitioner, verify that:

• An MD/DO has reviewed and signed all records that were open at the time of the

review, and all inpatient records that were closed since the MD/DO’s last review;

and

• That reviews take place within the timeframe specified by the CAH’s policy.

• If State law requires a physician to review or co-sign (or both) any outpatient

records of patients whose care is/was managed by non-physician practitioner,

determine whether an MD or DO has reviewed and/or co-signed a representative

sample of these records within the timeframe specified in the CAH’s policies.

• Ask the CAH how many outpatient encounters are managed by non-physician

practitioners, what sample size its policy requires to have an MD/DO review, and

what timeframe its policy specifies for reviews.

• Ask the CAH to explain how it ensures the sample is representative of the various

non-physician practitioners as well as of the various types of outpatient services

they provide.

• Ask the CAH to describe the method it uses to make sure that reviews are

performed in a timely manner on a sample that complies with the CAH’s policy.

• Review selected records from the CAH’s outpatient sample to verify that there is

evidence of an MD or DO review and/or signature.