Understanding CMS Requriements for Credentialing and ...

1 Understanding CMS Requriements for Credentialing and Privileging Understanding CMS. Requirements for Credentialing , Recredentialing, and Privileging in Hospitals and Managed Care Kathy Matzka, CPMSM, CPCS. 1304 Scott Troy Rd, Lebanon, IL 62254. (618) 624-8124. CMS Hospital CoPs All Interpretative guidelines and manuals are on website Rev. 137, 04-01-15 (most recent hospital). Guidance/Guidance/Manuals/downloads/som1 07ap_a_hos Rev. 110, 10-10-14 most recent CAH. Guidance/Guidance/Manuals/ Most recent rule changes for MS posted in Federal Register May 12, 2014. 2. CMS Hospital Page 3. Kathy Matzka, CPMSM, CPCS 1. Understanding CMS Requriements for Credentialing and Privileging Surveyor & Certification Memos 4. Document Review Hospital and CAH. Medical Staff Bylaws , Rules & Regulations Credential files to determine if the facility complies with CMS requirements and State law, as well as, follows its own written policies for medical staff privileges and Credentialing Personnel files to determine if staff members have the appropriate educational requirements, have had the necessary training required, and are licensed, if it is required (c) Kathy Matzka, CPMSM, CPCS 5.

2 Medicare Conditions of Participation Hospital and CAH. CoPs require criteria for determining privileges and for applying the criteria: Individual character Individual competence Individual training Individual experience Individual judgment (c) Kathy Matzka, CPMSM, CPCS 6. Kathy Matzka, CPMSM, CPCS 2. Understanding CMS Requriements for Credentialing and Privileging Hospital Sec. (a) MS. Composition The medical staff must be composed of MDs and DOs In accordance with State law, including scope-of- practice laws, the medical staff may also include other categories of physicians (as listed at . (c)(1) MD/DO/DDs/DMD/DPM/DC/OD). and non-physician practitioners who are determined to be eligible for appointment by the governing body. (c) Kathy Matzka, CPMSM, CPCS 7. Hospital IG - (a)(1). For physician practitioners granted privileges only, the hospital's governing body and its medical staff must exercise oversight, such as through Credentialing and competency review, of those other physician practitioners to whom it grants privileges, just as it would for those practitioners appointed to its medical staff CMS expects that all physician practitioners granted privileges are also appointed as unless State law limits the composition of the hospital's medical staff to certain categories of practitioners (c) Kathy Matzka, CPMSM, CPCS 8.

3 Survey Procedures (a)(1). Review documentation and verify that the governing body has determined and stated the categories of physicians and practitioners that are eligible candidates for appointment to the medical staff or to be granted medical staff privileges. (c) Kathy Matzka, CPMSM, CPCS 9. Kathy Matzka, CPMSM, CPCS 3. Understanding CMS Requriements for Credentialing and Privileging Hospital IG (a)(1). Other types of licensed healthcare professionals have a more limited scope of practice and usually are not eligible for hospital medical staff privileges, unless their permitted scope of practice in their State makes them more comparable to the above listed types of non-physician practitioners Examples: PT, OT, speech language therapist, clinical pharmacists (c) Kathy Matzka, CPMSM, CPCS 10. Hospital IG (a)(1) Medical Staff . If allowed by State law non-physician practitioners may be appointed Physician assistant Nurse practitioner.

4 Clinical nurse specialist Certified registered nurse anesthetist Certified nurse-midwife Clinical social worker Clinical psychologist Anesthesiologist's assistant Registered dietician or nutrition professional (c) Kathy Matzka, CPMSM, CPCS 11. Hospital (a)(2). MS must examine the credentials of all eligible candidates for MS membership and make recommendations to the GB on the appointment of these candidates in accordance with State law, including scope-of-practice laws, and MS bylaws, R&R. A candidate who has been recommended by the MS and who has been appointed by the GB is subject to all MS bylaws, R&R, in addition to the requirements contained in this (c) Kathy Matzka, CPMSM, CPCS 12. Kathy Matzka, CPMSM, CPCS 4. Understanding CMS Requriements for Credentialing and Privileging Admitting privileges Hospital and CAH. Licensed practitioners ( , nurse practitioners, midwives, etc.)

5 , as allowed by the State may admit patients Medicare patients under care of MD, DO, DDS, DPM, OD, DC, PhD (scope of practice as permitted by law). If a Medicare patient is admitted by a practitioner not specified, patient is under the care of a MD/DO. (c) Kathy Matzka, CPMSM, CPCS 13. Hospital IG (a)(2) Medical Staff The individual's credentials to be examined must include at least: A request for clinical privileges;. Evidence of current licensure;. Evidence of training and professional education;. Documented experience; and Supporting references of competence. (c) Kathy Matzka, CPMSM, CPCS 14. Hospital Interpretative Guidelines (a)(2) Medical Staff Must have a separate credentials file for each individual (c) Kathy Matzka, CPMSM, CPCS 15. Kathy Matzka, CPMSM, CPCS 5. Understanding CMS Requriements for Credentialing and Privileging Credentials Files What goes in?

6 Format (sections, tabs, etc.). File retention policy How long to keep What to keep Access Electronic (c) Kathy Matzka, CPMSM, CPCS 16. Hospital Interpretative Guidelines (a)(2) Medical Staff It cannot be assumed that every practitioner can perform every task/activity/privilege that is specified for the applicable category of practitioner. The individual practitioner's ability to perform each task/activity/privilege must be individually assessed (c) Kathy Matzka, CPMSM, CPCS 17. Sample Privilege Form Language Core or Category If you do not wish to request or perform a procedure/privilege appearing on this list, please cross it off the list and initial (or write in below). List Please limit your requests to those procedure/privileges that you will be performing at this facility and which your professional liability insurance will cover. 18. Kathy Matzka, CPMSM, CPCS 6.

7 Understanding CMS Requriements for Credentialing and Privileging Transference of Skill A transference of skill occurs when the same skills are utilized for different procedures If a physician has not performed a specific procedure, but has performed another procedure where those skills would transfer these can be grouped together May not apply to surgeries requiring more specialized skills or for complex surgeries not regularly performed (c) Kathy Matzka, CPMSM, CPCS 19. CAH Surgical services If CAH provides surgical services, surgical procedures must be performed in a safe manner by qualified practitioners who have been granted clinical privileges by the GB or responsible individual in accordance with the designation requirements under this section (c) Kathy Matzka, CPMSM, CPCS 20. Surgical Services Hospital and CAH. Must specify the surgical privileges for each practitioner that performs surgical tasks MD/DO, DMD, DDS, DPM, RNFA, NP, surgical PA, surgical technicians, etc.

8 If under supervision, the specific tasks/procedures and the degree of supervision (to include whether or not the supervising practitioner is physically present in the same OR, in line of sight of the practitioner being supervised) delineated in that practitioner's surgical privileges and included on the surgical roster. 21. Kathy Matzka, CPMSM, CPCS 7. Understanding CMS Requriements for Credentialing and Privileging Definition of Surgery - ACS. Surgery is performed for the purpose of structurally altering the human body by the incision or destruction of tissues and is part of the practice of medicine. Surgery also is the diagnostic or therapeutic treatment of conditions or disease processes by any instruments causing localized alteration or transposition of live human tissue which include lasers, ultrasound, ionizing radiation, scalpels, probes, and needles . 22.

9 Hospital IG (a)(4). If the hospital utilizes RNFA, surgical PA, or other non-MD/DO surgical assistants, it must establish criteria, qualifications and a Credentialing process to grant specific privileges based compliance with the privileging/ Credentialing criteria and in accordance with Federal and State laws and regulations Includes surgical services tasks conducted by these practitioners while under the supervision of an MD/DO. 23. CAH (a). MS bylaws include criteria for determining the privileges to be granted and procedure for applying the criteria Surgical privileges granted in accordance with the competencies of each practitioner MS appraisal procedures must evaluate each individual practitioner's training, education, experience, and demonstrated competence as established by the CAH'S. QA program, Credentialing process, the practitioner's adherence to CAH policies and procedures, and in accordance with scope of practice and other State laws and regulations (c) Kathy Matzka, CPMSM, CPCS 24.

10 Kathy Matzka, CPMSM, CPCS 8. Understanding CMS Requriements for Credentialing and Privileging Hospital and CAH. Surgical privileges reviewed and updated at least every 2 years Current roster and suspension/restriction list in surgical suite and wherever scheduling performed (c) Kathy Matzka, CPMSM, CPCS 25. Hospital IG (a)(2) Medical Staff Practitioner and appropriate hospital patient care areas/departments are informed of the privileges granted to the practitioner (c) Kathy Matzka, CPMSM, CPCS 26. Communicating to Stakeholders Practitioners Hospital Staff Department chief External entities See sample policy and procedure (c) Kathy Matzka, CPMSM, CPCS 27. Kathy Matzka, CPMSM, CPCS 9. Understanding CMS Requriements for Credentialing and Privileging Survey Procedures Hospital and CAH. Review the hospital's method for reviewing the surgical privileges of practitioners.