II 

113TH CONGRESS 

1ST SESSION S. 1143 

To amend title XVIII of the Social Security Act with respect to physician 

supervision of therapeutic hospital outpatient services. 

IN THE SENATE OF THE UNITED STATES 

JUNE 12, 2013 

Mr. MORAN (for himself, Mr. THUNE, and Mr. TESTER) introduced the 

following bill; which was read twice and referred to the Committee on Finance 

A BILL 

To amend title XVIII of the Social Security Act with respect 

to physician supervision of therapeutic hospital outpatient services. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Protecting Access to 

5 Rural Therapy Services (PARTS) Act’’. 

6 SEC. 2. REQUIREMENTS FOR PHYSICIAN SUPERVISION OF 

7 THERAPEUTIC HOSPITAL OUTPATIENT SERV8 ICES. 

9 (a) THERAPEUTIC HOSPITAL OUTPATIENT SERV10 ICES.— 

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1 (1) SUPERVISION REQUIREMENTS.—Section 

2 1833 of the Social Security Act (42 U.S.C. 1395l) 

3 is amended by adding at the end the following new 

4 subsection: 

5 ‘‘(z) PHYSICIAN SUPERVISION REQUIREMENTS FOR

6 THERAPEUTIC HOSPITAL OUTPATIENT SERVICES.— 

7 ‘‘(1) GENERAL SUPERVISION FOR THERAPEUTIC

8 SERVICES.—Except as may be provided under para9 graph (2), insofar as the Secretary requires the su10 pervision by a physician or a non-physician practi11 tioner for payment for therapeutic hospital out12 patient services (as defined in paragraph (5)(A)) 

13 furnished under this part, such requirement shall be 

14 met if such services are furnished under the general 

15 supervision (as defined in paragraph (5)(B)) of the 

16 physician or non-physician practitioner, as the case 

17 may be. 

18 ‘‘(2) EXCEPTIONS PROCESS FOR HIGH-RISK OR

19 COMPLEX MEDICAL SERVICES REQUIRING A DIRECT

20 LEVEL OF SUPERVISION.— 

21 ‘‘(A) IN GENERAL.—Subject to the suc22 ceeding provisions of this paragraph, the Sec23 retary shall establish a process for the designa24 tion of therapeutic hospital outpatient services 

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1 furnished under this part that, by reason of 

2 complexity or high risk, require— 

3 ‘‘(i) direct supervision (as defined in 

4 paragraph (5)(C)) for the entire service; or 

5 ‘‘(ii) direct supervision during the ini6 tiation of the service followed by general 

7 supervision for the remainder of the serv8 ice. 

9 ‘‘(B) CONSULTATION WITH CLINICAL EX10 PERTS.— 

11 ‘‘(i) IN GENERAL.—Under the process 

12 established under subparagraph (A), before 

13 the designation of any therapeutic hospital 

14 outpatient service for which direct super15 vision may be required under this part, the 

16 Secretary shall consult with a panel of out17 side experts described in clause (ii) to ad18 vise the Secretary with respect to each 

19 such designation. 

20 ‘‘(ii) ADVISORY PANEL ON SUPER21 VISION OF THERAPEUTIC HOSPITAL OUT22 PATIENT SERVICES.—For purposes of 

23 clause (i), a panel of outside experts de24 scribed in this clause is a panel appointed 

25 by the Secretary, based on nominations 

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1 submitted by hospital, rural health, and 

2 medical organizations representing physi3 cians, non-physician practitioners, and hos4 pital administrators, as the case may be, 

5 that meets the following requirements: 

6 ‘‘(I) COMPOSITION.—The panel 

7 shall be composed of at least 15 phy8 sicians and non-physician practi9 tioners who furnish therapeutic hos10 pital outpatient services for which 

11 payment is made under this part and 

12 who collectively represent the medical 

13 specialties that furnish such services, 

14 and of 4 hospital administrators of 

15 hospitals located in rural areas (as de16 fined in section 1886(d)(2)(D)) or 

17 critical access hospitals. 

18 ‘‘(II) PRACTICAL EXPERIENCE

19 REQUIRED FOR PHYSICIANS AND NON20 PHYSICIAN PRACTITIONERS.—During 

21 the 12-month period preceding ap22 pointment to the panel by the Sec23 retary, each physician or non-physi24 cian practitioner described in sub25 clause (I) shall have furnished theramstockstill on DSK4VPTVN1PROD with BILLS

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1 peutic hospital outpatient services for 

2 which payment was made under this 

3 part. 

4 ‘‘(III) MINIMUM RURAL REP5 RESENTATION REQUIREMENT FOR

6 PHYSICIANS AND NON-PHYSICIAN

7 PRACTITIONERS.—Not less than 50 

8 percent of the membership of the 

9 panel that is comprised of physicians 

10 and non-physician practitioners shall 

11 be physicians or non-physician practi12 tioners described in subclause (I) who 

13 practice in rural areas (as defined in 

14 section 1886(d)(2)(D)) or who furnish 

15 such services in critical access hos16 pitals. 

17 ‘‘(iii) APPLICATION OF FACA.—The 

18 Federal Advisory Committee Act (5 U.S.C. 

19 2 App.), other than section 14 of such Act, 

20 shall apply to the panel of outside experts 

21 appointed by the Secretary under clause 

22 (ii). 

23 ‘‘(C) SPECIAL RULE FOR OUTPATIENT

24 CRITICAL ACCESS HOSPITAL SERVICES.—Inso25 far as a therapeutic outpatient hospital service 

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1 that is an outpatient critical access hospital 

2 service is designated as requiring direct super3 vision under the process established under sub4 paragraph (A), the Secretary shall deem the 

5 critical access hospital furnishing that service 

6 as having met the requirement for direct super7 vision for that service if, when furnishing such 

8 service, the critical access hospital meets the 

9 standard for personnel required as a condition 

10 of participation under section 485.618(d) of 

11 title 42, Code of Federal Regulations (as in ef12 fect on the date of the enactment of this sub13 section). 

14 ‘‘(D) CONSIDERATION OF COMPLIANCE

15 BURDENS.—Under the process established 

16 under subparagraph (A), the Secretary shall 

17 take into account the impact on hospitals and 

18 critical access hospitals in complying with re19 quirements for direct supervision in the fur20 nishing of therapeutic hospital outpatient serv21 ices, including hospital resources, availability of 

22 hospital-privileged physicians, specialty physi23 cians, and non-physician practitioners, and ad24 ministrative burdens. 

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1 ‘‘(E) REQUIREMENT FOR NOTICE AND

2 COMMENT RULEMAKING.—Under the process 

3 established under subparagraph (A), the Sec4 retary shall only designate therapeutic hospital 

5 outpatient services requiring direct supervision 

6 under this part through proposed and final 

7 rulemaking that provides for public notice and 

8 opportunity for comment. 

9 ‘‘(F) RULE OF CONSTRUCTION.—Nothing 

10 in this subsection shall be construed as author11 izing the Secretary to apply or require any level 

12 of supervision other than general or direct su13 pervision with respect to the furnishing of 

14 therapeutic hospital outpatient services. 

15 ‘‘(3) INITIAL LIST OF DESIGNATED SERVICES.— 

16 The Secretary shall include in the proposed and final 

17 regulation for payment for hospital outpatient serv18 ices for 2015 under this part a list of initial thera19 peutic hospital outpatient services, if any, designated 

20 under the process established under paragraph 

21 (2)(A) as requiring direct supervision under this 

22 part. 

23 ‘‘(4) DIRECT SUPERVISION BY NON-PHYSICIAN

24 PRACTITIONERS FOR CERTAIN HOSPITAL OUT25 PATIENT SERVICES PERMITTED.— 

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1 ‘‘(A) IN GENERAL.—Subject to the suc2 ceeding provisions of this subsection, a non-phy3 sician practitioner may directly supervise the 

4 furnishing of— 

5 ‘‘(i) therapeutic hospital outpatient 

6 services under this part, including cardiac 

7 rehabilitation services (under section 

8 1861(eee)(1)), intensive cardiac rehabilita9 tion services (under section 1861(eee)(4)), 

10 and pulmonary rehabilitation services 

11 (under section 1861(fff)(1)); and 

12 ‘‘(ii) those hospital outpatient diag13 nostic services (described in section 

14 1861(s)(2)(C)) that require direct super15 vision under the fee schedule established 

16 under section 1848. 

17 ‘‘(B) REQUIREMENTS.—Subparagraph (A) 

18 shall apply insofar as the non-physician practi19 tioner involved meets the following require20 ments: 

21 ‘‘(i) SCOPE OF PRACTICE.—The non22 physician practitioner is acting within the 

23 scope of practice under State law applica24 ble to the practitioner. 

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1 ‘‘(ii) ADDITIONAL REQUIREMENTS.— 

2 The non-physician practitioner meets such 

3 requirements as the Secretary may specify. 

4 ‘‘(5) DEFINITIONS.—In this subsection: 

5 ‘‘(A) THERAPEUTIC HOSPITAL OUT6 PATIENT SERVICES.—The term ‘therapeutic 

7 hospital outpatient services’ means hospital 

8 services described in section 1861(s)(2)(B) fur9 nished by a hospital or critical access hospital 

10 and includes— 

11 ‘‘(i) cardiac rehabilitation services and 

12 intensive cardiac rehabilitation services (as 

13 defined in paragraphs (1) and (4), respec14 tively, of section 1861(eee)); and 

15 ‘‘(ii) pulmonary rehabilitation services 

16 (as defined in section 1861(fff)(1)). 

17 ‘‘(B) GENERAL SUPERVISION.— 

18 ‘‘(i) OVERALL DIRECTION AND CON19 TROL OF PHYSICIAN.—Subject to clause 

20 (ii), with respect to the furnishing of 

21 therapeutic hospital outpatient services for 

22 which payment may be made under this 

23 part, the term ‘general supervision’ means 

24 such services that are furnished under the 

25 overall direction and control of a physician 

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1 or non-physician practitioner, as the case 

2 may be. 

3 ‘‘(ii) PRESENCE NOT REQUIRED.—For 

4 purposes of clause (i), the presence of a 

5 physician or non-physician practitioner is 

6 not required during the performance of the 

7 procedure involved. 

8 ‘‘(C) DIRECT SUPERVISION.— 

9 ‘‘(i) PROVISION OF ASSISTANCE AND

10 DIRECTION.—Subject to clause (ii), with 

11 respect to the furnishing of therapeutic 

12 hospital outpatient services for which pay13 ment may be made under this part, the 

14 term ‘direct supervision’ means that a phy15 sician or non-physician practitioner, as the 

16 case may be, is immediately available (in17 cluding by telephone or other means) to 

18 furnish assistance and direction through19 out the furnishing of such services. Such 

20 term includes, with respect to the fur21 nishing of a therapeutic hospital outpatient 

22 service for which payment may be made 

23 under this part, direct supervision during 

24 the initiation of the service followed by 

25 general supervision for the remainder of 

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1 the service (as described in paragraph 

2 (2)(A)(ii)). 

3 ‘‘(ii) PRESENCE IN ROOM NOT RE4 QUIRED.—For purposes of clause (i), a 

5 physician or non-physician practitioner, as 

6 the case may be, is not required to be 

7 present in the room during the perform8 ance of the procedure involved or within 

9 any other physical boundary as long as the 

10 physician or non-physician practitioner, as 

11 the case may be, is immediately available. 

12 ‘‘(D) NON-PHYSICIAN PRACTITIONER DE13 FINED.—The term ‘non-physician practitioner’ 

14 means an individual who— 

15 ‘‘(i) is a physician assistant, a nurse 

16 practitioner, a clinical nurse specialist, a 

17 clinical social worker, a clinical psycholo18 gist, a certified nurse midwife, or a cer19 tified registered nurse anesthetist, and in20 cludes such other practitioners as the Sec21 retary may specify; and 

22 ‘‘(ii) with respect to the furnishing of 

23 therapeutic outpatient hospital services, 

24 meets the requirements of paragraph 

25 (4)(B).’’. 

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1 (2) CONFORMING AMENDMENT.—Section 

2 1861(eee)(2)(B) of the Social Security Act (42 

3 U.S.C. 1395x(eee)(2)(B)) is amended by inserting ‘‘, 

4 and a non-physician practitioner (as defined in sec5 tion 1833(z)(5)(D)) may supervise the furnishing of 

6 such items and services in the hospital’’ after ‘‘in 

7 the case of items and services furnished under such 

8 a program in a hospital, such availability shall be 

9 presumed’’. 

10 (b) PROHIBITION ON RETROACTIVE ENFORCEMENT

11 OF REVISED INTERPRETATION.— 

12 (1) REPEAL OF REGULATORY CLARIFICA13 TION.—The restatement and clarification under the 

14 final rulemaking changes to the Medicare hospital 

15 outpatient prospective payment system and calendar 

16 year 2009 payment rates (published in the Federal 

17 Register on November 18, 2008, 73 Fed. Reg. 

18 68702 through 68704) with respect to requirements 

19 for direct supervision by physicians for therapeutic 

20 hospital outpatient services (as defined in paragraph 

21 (3)) for purposes of payment for such services under 

22 the Medicare program shall have no force or effect 

23 in law. 

24 (2) HOLD HARMLESS.—A hospital or critical 

25 access hospital that furnishes therapeutic hospital 

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1 outpatient services during the period beginning on 

2 January 1, 2001, and ending on the later of Decem3 ber 31, 2014, or the date on which the final regula4 tion promulgated by the Secretary of Health and 

5 Human Services to carry out this Act takes effect, 

6 for which a claim for payment is made under part 

7 B of title XVIII of the Social Security Act shall not 

8 be subject to any civil or criminal action or penalty 

9 under Federal law for failure to meet supervision re10 quirements under the regulation described in para11 graph (1), under program manuals, or otherwise. 

12 (3) THERAPEUTIC HOSPITAL OUTPATIENT

13 SERVICES DEFINED.—In this subsection, the term 

14 ‘‘therapeutic hospital outpatient services’’ means 

15 medical and other health services furnished by a 

16 hospital or critical access hospital that are— 

17 (A) hospital services described in sub18 section (s)(2)(B) of section 1861 of the Social 

19 Security Act (42 U.S.C. 1395x); 

20 (B) cardiac rehabilitation services or inten21 sive cardiac rehabilitation services (as defined 

22 in paragraphs (1) and (4), respectively, of sub23 section (eee) of such section); or 

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1 (C) pulmonary rehabilitation services (as 

2 defined in subsection (fff)(1) of such section). 

Æ 

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