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CMS Clarifies Co-Signing of Orders

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August 19, 2009

CMS has clarified their advice on RTs carrying out orders written by nurse practitioners (NPs) or physician assistants (PAs). And they say it’s okay, as long as a physician co-signs within a designated period of time.

The Government Affairs staff sought the advice of the Centers for Medicare and Medicaid Services (CMS) after several inquiries came in from members who asked for clarification as to whether RTs can carry out orders written by NPs and PAs. Questions have arisen as a result of The Joint Commission’s policy PC. which states:

“For hospitals that use Joint Commission accreditation for deemed status purposes: Respiratory services are provided only on, and in accordance with, the orders of a doctor of medicine or osteopathy.”

Some members are confused that this is a new policy. It is not. The Medicare Hospital Conditions of Participation (CoPs) and the Interpretive Guidelines regarding respiratory care services have been in place for many years and it is these federal Medicare standards upon which the Joint Commission standards are written.

Although respiratory care services are an optional hospital CoP, any hospital that provides such services must adhere to these requirements. According to the Centers for Medicare and Medicaid Services (CMS), the Interpretive Guidelines were recently updated but the particular requirement that RTs follow the orders of a MD/DO did not change.

We have been informed that some respiratory therapy departments deal with the standards by having all orders written by NPs or PAs co-signed by a physician within 24 hours. So we asked CMS to elaborate on whether this was acceptable in meeting the standards. Here’s what CMS staff said:

“Basically, MDs/DOs can delegate the writing of orders or other duties to NPs/PAs, as long as it is in accordance with State law and hospital policy. However, as a delegated duty, the MDs/DOs would need to co-sign. As far as the timeframe for the co-signature goes, the CoPs do not speak to this directly and would defer to any State law and any hospital policies regarding the timing. Surveyors would look to the hospital policies and State law to make sure that all requirements regarding delegation of duties and co-signatures were in place. If a hospital established a policy of co-signature within 24 hours, which was consistent with any state laws, then it wouldn’t necessarily be non-compliant if the surveyor looked at the record within the 24-hr period and the doc hadn’t co-signed it yet; it would only be a problem if the lack of signature went beyond the 24-hr timeframe established in the hospital’s policies.”

CMS’ advice is straightforward, and we hope it helps alleviate any questions on the part of RTs and their respective departments as to compliance with hospital standards.