28 AE Fall eZine 2011

Physician is defined as a “doctorof medicine or osteopathy, a doctorof dental surgery or dental medicine,and a doctor of podiatric medicine”per the Social Security Act. Thephysician must be licensed in thestate and practicing within the scopeof his/her license. Privileges cannotbe granted until the physician hasbeen deemed qualified. The govern-ing body is specifically responsiblefor reviewing applicant qualificationsand granting privileges. The facilitymust have a written policy and pro-cedure, which clearly defines thisprocess and qualification criteria. Inmost cases this process is outlined inthe medical staff bylaws.

M any ASCs havereceived deficiencycitations for medicalstaff credentialingand privileging over

the last 2 years. This article willreview the applicable CMS condi-tions and standards and best prac-tices to ensure compliance.

416.42 Condition forCoverage: Surgical ServicesSurgical procedures must be performedin a safe manner by qualified physi-cians who have been granted clinicalprivileges by the governing body of theASC in accordance with approved poli-cies and procedures of the ASC.

Medical Staff Credentialing in the ASC

Fall eZine 2011 ASC

Regina Boore, RN, BSN, MS

416.45 Condition forCoverage: Medical StaffThe medical staff of the ASC must beaccountable to the governing body.

While medical staff organizationis discretionary, the governing bodymust have a clearly defined policyand process that defines how themedical staff is held accountable tothe governing body. Medical staffprivileges may be granted to non-physician providers, as long as thoseprivileges are consistent with theirpermitted scope of practice in thestate and supported by documentedevidence of appropriate training andexperience.

416.45(a) Standard:Membership and Clinical PrivilegesMembers of the medical staff must belegally and professionally qualified forthe positions to which they are appoint-ed and for the performance of privilegesgranted. The ASC grants privileges inaccordance with recommendations fromqualified medical personnel.

Privileges granted by the govern-ing body must be specific, in writing,and may only be granted to thoselegally and professionally qualified.Legal qualification requires knowl-edge of the license scope of practiceand verification of the license withthe issuing authority in the state.Professional qualification means theapplicant is competent to perform therequested privileges. Documentationof specialized training and experienceis evidence of competence.

AE Fall eZine 2011 29

Additionally, the ASC is required tosolicit the opinion of qualified med-ical personnel with knowledge of theapplicant. This opinion must be inwriting with supporting rationale.The reference source may be a mem-ber of the ASC medical staff or anoutside physician with no connectionto the ASC. In fact, in single-ownerASCs with only one physician on themedical staff, the opinion of an out-side qualified medical professional isrequired. The governing body is notobliged to adhere to the recommen-dation of the outside professional;however, the rationale for making adecision to the contrary must be doc-umented.

The processes by which theapplicant is vetted and the govern-ing body grants medical staff privi-leges must be consistent and thor-oughly documented. Typically, theapplicant submits the following tothe ASC:• Request for staff appointment• Completed application including

liability questionnaire with expla-nations when applicable

• Authorization to release informa-tion

• Completed “Privilege Request”form

• Copy of professional liability cov-erage with limits that meet orexceed facility requirements

• Copy of medical license, DEA per-mit, and other certifications (suchas ACLS) as applicable

• Peer referencesOnce received, the ASC must

verify the information and creden-tials provided by the applicant. Thisprocess is involved and requires greatattention to detail. Large organiza-tions may opt to use a credentialingverification organization (CVO) tocomplete the process. Once the filesare complete, the documentation isdelivered to the ASC for review andappointment.

Smaller organizations typicallymanage the credentialing process in

house. Verification of education andtraining may be obtained from theprimary sources, such as the educa-tional institutions from which theapplicant graduated. This is cumbersome and time consuming.Alternatively, verification may beobtained through a qualified second-ary source. In the case of MDs, aphysician profile from the AmericanMedical Association (AMA) is accept-able as secondary source verification.To obtain AMA physician profiles, goto https://profiles.ama-assn.org/amaprofiles/ and click on “new cus-tomer registration.” The AmericanOsteopathic Association providesthis service for DOs. You can obtainAOA physician profiles atwww.doprofiles.org/index.cfm.

Other credentials such as med-ical license and DEA permit must beverified through the appropriatestate or federal issuing agency.Verification of hospital privilegesmust be done through the primarysource. Many hospitals now allowyou to manage this process online.The CMS standard specificallyrequires peer references. It is goodpractice to request at least three peerreferences and require a minimum oftwo completed peer references forreview and consideration prior toappointment.

Additionally, the ASC must regis-ter with the National PractitionerDatabase-Healthcare IntegrityDatabase as an Authorized Entity(NPDB) at www.npdb-hipdb.hrsa.gov/hcorg/ register.jsp. Once regis-tered, an NPDB query should berequested for the applicant andavailable for review by the creden-tials committee. This will documentany settlements or judgments againstthe applicant.

Verification of exclusion fromthe Medicare/Medicaid program isobtained at the OIG websitehttp://exclusions.oig.hhs.gov/. Basisfor exclusion includes convictionsfor program-related fraud andpatient abuse, licensing boardactions, and default on HealthEducation Assistance Loans.

Once the verification process iscompleted, all of this documentationmust be compiled and organized forpresentation to the credentialingcommittee. The committee recom-mendation is forwarded to the gov-erning body, which ultimately actsupon that recommendation byappointing the applicant to the med-ical staff.

416.45(b) Standard:ReappraisalsMedical staff privileges must be periodi-cally reappraised by the ASC. The scopeof procedures performed in the ASCmust be periodically reviewed andamended as appropriate.

The term of appointment formedical staff membership is definedin the medical staff bylaws. CMS rec-ommends the term not be longerthan 2 years. Every 2 years, the staffmember must reapply and his/hercredentials must be reappraised. Inaddition, quality and peer reviewdata must be documented and con-sidered in the reappointmentprocess. Based on this documenta-tion, the ASC governing body may

Failure to properlydocument andimplement yourcredentialing andprivileging processcan result in atleast two CMS condition level citations.

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elect to reappoint the provider withno change to the current privilegesgranted or to amend those privilegesin some way. In the case of a soleowner/single member medical staff,the reappointment process mustinclude review and recommendationof outside qualified medical person-nel.

416.45(c) Standard: OtherPractitionersIf the ASC assigns patient care responsi-bilities to practitioners other than physi-cians, it must have established policiesand procedures, approved by the govern-ing body, for overseeing and evaluatingtheir clinical activities.

Patient care responsibilities (whichmay or may not include formal medicalstaff privileges, but excluding nursingcare services) may be assigned tolicensed practitioners not meeting thedefinition of physician in §1861(r) ofthe 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 per-formed in the State; and

• Chiropractor with respect to treatmentby manual manipulation of the spine(to correct subluxation diagnosed byx-ray).

When non-physician practition-ers provide patient care in the ASC,other than nursing care, the ASCmust have clearly defined policiesand procedures to establish a systemfor overseeing and evaluating thequality of the clinical services pro-vided by those practitioners. In anophthalmic ASC, the typical scenarioinvolves the use of certified regis-tered nurse anesthetists (CRNA) foranesthesia services. In such cases, theASC must develop policies to definerequired qualifications, the creden-tialing process, scope of practice,

oversight and supervision, and peri-odic reappraisal.

AdviceFailure to properly document andimplement your credentialing andprivileging process can result in atleast two CMS condition level cita-tions. If you have not visited thisprocess recently in your ASC, itbehooves you to review your medicalstaff bylaws, scope of care, privilegerequest forms, credentialing process,and peer review process to ensureyour facility is in compliance withthese conditions and standards. AE

practice owns the space in which theASC resides. Medicare has no author-ity to dictate to the practice how itutilizes its physical space apart fromthe ASC operation. They do haveauthority to dictate how the practiceoperates the ASC. I have a client whoused the lobby for a wedding recep-tion on a weekend. CMS would nothave anything to say about that.

Where I have seen CMS pushback on this concept is in a practiceowned and adjacent to the ASCwhere the lines of distinction anddemarcation between the practiceand ASC operations are blurred orindistinct. Remember, the intent ofthis regulation is to preclude fraudand abuse—that is, to use the ASCspace as clinic space but bill CMS afacility fee. This abuse most com-

monly occurs with a YAG laser locat-ed in the ASC. When it is used dur-ing non-operating ASC hours, yetbilled as an ASC facility, that isfraud.

In the case of LASIK, fraud andabuse is not an issue. That said, CMSis very sensitive on this issue, andmeeting the definition of an ASC asa distinctly separate entity from anyother organization is the very firstcondition for coverage. Therefore, itis wise for ASCs utilizing their facili-ty during non-ASC operating hours,for ANY PURPOSE, to make it a non-issue to a visiting surveyor. It shouldnot be obvious in any way thatwould make the surveyors aware ofthe fact or prompt questions. It is adisadvantage if the excimer laser islocated in the ASC. Easier for a roll

on, roll off. If the excimer laser islocated in the ASC, it should be usedonly on a day the ASC is not operat-ing—this is cleaner than “splitting” aday between operations (a.m./p.m.).Staff should be clear on the regula-tions and understand how torespond to surveyors if questionsabout this issue surface.

I would steer clear of calling thisan “exemption,” and I suspect thismay be language that created a prob-lem with CMS. CMS is very clearthat there can only be one standardof care in a CMS-certified ASC—it isnot dictated by the complexity ofthe procedure, the type of anesthe-sia, the reimbursement status, or thepayer. There is no such thing as anexception or exemption in aMedicare-certified ASC. AE

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Regina Boore, RN, BSN, MS(rboore@PSS4ASC.com), ispresident of ProgressiveSurgical Solutions LLC, an ASCdevelopment and consultingfirm based in San Diego, Calif.