Guideline text:
(Rev.78, Issued: 12-22-11, Effective/Implementation: 12-22-11)

## [The governing body must:]

§482.12(a)(8)  Ensure that, when telemedicine services are furnished to the hospital's patients through an agreement with a distant-site hospital, the agreement is written and that it specifies that it is the responsibility of the governing body of the distant-site hospital to meet the requirements in paragraphs (a)(1) through (a)(7) of this section with regard to  the distant -site hospital's physicians and practitioners providing telemedicine services.  The governing body of the hospital whose patients are receiving the telemedicine services may, in accordance with §482.22(a)(3) of this part, grant privileges based on its medical staff recommendations that rely on information provided by the distant-site hospital.

§482.12(a)(9)  Ensure that when telemedicine services are furnished to the hospital's patients through an agreement with a distant-site telemedicine entity, the  written agreement specifies that the distant-site telemedicine entity is a contractor of services to the hospital and as such, in accordance with §482.12(e), furnishes the contracted services in a manner that permits the hospital to comply with all applicable conditions of participation for the contracted services, including, but not limited to, the requirements in paragraphs (a)(1) through (a)(7) of this section with regard to the distant-site telemedicine entity's physicians and practitioners providing telemedicine services.  The governing body of the hospital whose patients are receiving the telemedicine services may, in accordance with §482.22(a)(4) of this part, grant privileges to physicians and practitioners employed by the distant-site telemedicine entity  based on such hospital's medical staff recommendations; such staff recommendations may  rely on information provided by the distant-site telemedicine entity.

## Interpretive Guidelines §482.12(a)(8)&amp;(a)(9)

'Telemedicine,' as the term is used in this regulation, means the provision of clinical services to patients by physicians and practitioners from a distance via electronic communications.  The distant-site telemedicine physician or practitioner provides clinical services to the hospital patient either simultaneously, as is often the case with teleICU services, for example, or non-simultaneously, as may be the case with many teleradiology services.  'Simultaneously' means that the clinical services (for example, assessment of the patient with a clinical plan for treatment, including any medical orders needed) are provided to the patient in 'real time' by the telemedicine physician or practitioner, similar to the actions of an on-site physician or practitioner.  'Non-simultaneously' means that, while the telemedicine physician or practitioner still provides clinical services to the patient upon a formal request from the patient's attending physician, such services may involve after-thefact interpretation of diagnostic tests in order to provide an assessment of the patient's condition and do not necessarily require the telemedicine practitioner to directly assess the patient in 'real time.'  This would be similar to the services provided by an on-site radiologist who interprets a patient's x-ray or CT scan and then communicates his or her assessment to the patient's attending physician who then bases his or her diagnosis and treatment plan on these findings.   (See 76 FR 25551-25552, May 5, 2011)

A hospital may make arrangements through written agreements either with a distant-site Medicare-participating hospital or a distant-site telemedicine entity for the provision of telemedicine services to the hospital's patients by physicians or practitioners who have been granted privileges by the distant-site hospital or telemedicine entity.   For the purposes of this rule, a distant-site telemedicine entity is defined as an entity that -- (1) provides telemedicine services; (2) is not a Medicare-participating hospital; and (3) provides contracted services in a manner that enables a hospital using its services to meet all applicable CoPs, particularly those requirements related to the credentialing and privileging of practitioners providing telemedicine services to the patients of a hospital.  A distant-site telemedicine entity would include a distant-site hospital that does not participate in the Medicare program that is providing telemedicine services to a Medicare-participating hospital. (See 76 FR 25553, May 5, 2011)

If a hospital enters into an agreement for telemedicine services with a distant-site hospital or telemedicine entity, the agreement must be in writing.  Furthermore, the written agreement must specify, in the case of a:

- Distant-site hospital, that it is the responsibility of the governing body of the distant-site hospital to satisfy the requirements of §§482.12(a)(1) through (a) (7) with respect to those physicians and practitioners at the distant-site hospital who furnish telemedicine services under the agreement.  Since the distant-site hospital must also be a Medicare-participating hospital (see §482.22(a)(3)), it has an independent obligation to comply with these governing body requirements concerning medical staff membership and privileging.  Nevertheless, the written agreement between the hospital and the distant-site hospital must explicitly include a provision addressing the distant-site hospital's obligation to comply with these provisions.
- Distant-site telemedicine entity, that the written agreement specifies that they entity is a contractor providing telemedicine services to the hospital, and that, in accordance with the requirements governing services under arrangement at §482.12(e), the telemedicine entity furnishes the contracted telemedicine services in a manner that permits the hospital to comply with the Conditions of Participation, including, but not limited to, the governing body requirements of §§482.12(a)(1) through (a) (7) with respect to those physicians and practitioners at the distant-site telemedicine entity who furnish telemedicine services under the agreement.

There are additional requirements for the content of the written agreement, specified at §482.22(a)(3) and §482.22(a)(4) under the medical staff Condition of Participation, which are discussed in the interpretive guidelines for those regulations.

The hospital's governing body must grant privileges to each telemedicine physician or practitioner providing services at the hospital under an agreement with a distant-site hospital or telemedicine entity before they may provide telemedicine services.  The scope of the privileges in the hospital must reflect the provision of the services via a telecommunications system.  For example, a surgeon at a distant-site hospital may provide telemedicine consultation services at a hospital under agreement, but obviously would not be able to perform surgery by this means and must not have surgical privileges in the hospital as part of his/her telemedicine services privileges.  If the surgeon also periodically performed surgery on-site at the hospital, then he or she would have to have privileges to do so, granted in the traditional manner provided for at §482.12(a)(1) through §482.12(a)(7) and §482.22(a)(1) and §482.22(a)(2).

In granting privileges to telemedicine physicians and practitioners, the hospital's governing body has the option of considering hospital medical staff recommendations that rely, in accordance with §482.22(a)(3) and §482.22(a)(4), upon the credentialing and privileging decisions of the distant-site hospital or telemedicine entity.  With respect to the decisions of a distant-site telemedicine entity, the regulation states that this streamlined privileging option is available to the hospital for physicians and practitioners 'employed' by the distant-site telemedicine entity.  We are interpreting 'employed' in this context to mean 'utilized by' the distant-site telemedicine entity to provide telemedicine services to the hospital under an agreement.  Since it is common for telemedicine entities to contract with, rather than employ, the physicians and practitioners it utilizes to provide telemedicine services, it would not be reasonable or consistent with the regulatory intent to interpret 'employed' to mean that the physicians or practitioners are employees of the distant-site telemedicine entity.

When the hospital's governing body exercises the option to grant privileges based on its medical staff recommendations that rely upon the privileging decisions of a distant-site telemedicine hospital or entity, it may, but is not required to, maintain a separate file on each telemedicine physician and practitioner, or may instead have a file on all telemedicine physicians and practitioners providing  services at the hospital under each agreement with a distant-site hospital or telemedicine entity, indicating which telemedicine services privileges the hospital has granted to each physician and practitioner on the list.

Relying upon the credentialing and privileging decisions of the distant-site hospital or telemedicine entity is an option available to the hospital's governing body, not a requirement.  A governing body may, if it so chooses, require its medical staff to independently review the credentials of and make privileging recommendations for each telemedicine physician and practitioner in accordance with §482.22(a)(1) and §482.22(a)(2), rather than permit its medical staff to rely upon the privileging decisions of the distant-site hospital or telemedicine entity.  The agreement with the distant-site hospital or telemedicine entity may not require the hospital to rely upon the distant-site organization's privileging decisions.

## Survey Procedures §482.12(a)(8)&amp;(a)(9)

- Ask the hospital's leadership whether it uses telemedicine services.  If yes:
- Ask to see a copy of the written agreement(s) with the distant-site hospital(s) or telemedicine entity(ies).  Does each agreement include the required elements concerning credentialing and privileging of the telemedicine physicians and practitioners?
- Does the hospital have documentation indicating that it granted privileges to each telemedicine physician and practitioner?
- Does the documentation indicate that for each telemedicine physician and practitioner there is a medical staff recommendation, including an indication of whether the medical staff conducted its own review or relied upon the decisions of the distant-site hospital or telemedicine entity?

Structured rule (JSON):
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