March 2014
The North Carolina Cardiopulmonary Rehabilitation Association, NCCRA, is concerned with a CMS
regulation for cardiac and pulmonary rehabilitation programs that specifically does not permit
supervision of these services by licensed Nurse Practitioners and Physician Assistants. This concern
has nothing to do with the fact that both services have a medical director who is responsible for
supervising the program, the staff, and the patients in that rehab program. This is about an additional
Medicare requirement for direct physician supervision.
CMS has ruled that as of 1-1-2010, NPPs (Non-Physician Practitioners such as nurse practitioners,
clinical nurse specialists, physician assistants) may provide aspects of direct physician supervision for
hospital outpatient services such as dialysis, anticoagulation, diabetic clinics and a wide range of other
hospital outpatient services, in accordance with respective scope of practice and state licensure laws,
except in the case of cardiac and pulmonary rehab services where a physician (MD or DO) must
provide direct supervision, according to CMS’ interpretation of Section 144 of PL 110-275. Original
sponsors of the legislation signaled to CMS that this was not the legislative intent of the provisions.
However, CMS responded that statutory language prohibits this change to be extended to cardiac and
pulmonary rehab services without intervention by Congress.
NPPs are presently used in the inpatient acute care setting, in collaboration with physicians to monitor
post-op cardiac patients. Cardiac and pulmonary rehabilitation services are for stable outpatients, so it
is reasonable to use qualified physician extenders in these settings as well.
The proposed solution is a technical correction that would apply the same rules for physician
supervision of pulmonary and cardiac rehab services in hospitals and critical access hospitals (CAHs)
as has been extended to other hospital outpatient services under direct physician supervision.
This technical correction amendment is necessary for cardiac and pulmonary rehabilitation programs in
our state and throughout the U.S. The current CMS interpretation of this regulation particularly
jeopardizes cardiac and pulmonary rehabilitation programs located in rural locations. It is anticipated
that the technical correction language will not impose any additional cost to Medicare since direct
physician supervision is a non-billable, non-reimbursable requirement.
The North Carolina Cardiopulmonary Rehabilitation Association is requesting that you become a
bipartisan co-sponsor for a very minor piece of legislation that will have a pronounced positive impact
for many outpatient hospital programs and patients.
Sincerely,