I 

113TH CONGRESS 

1ST SESSION H. R. 2801 

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

supervision of therapeutic hospital outpatient services. 

IN THE HOUSE OF REPRESENTATIVES 

JULY 23, 2013 

Mrs. NOEM (for herself, Mr. PETERSON, Mr. CRAMER, and Mr. DAINES) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and 

Means, for a period to be subsequently determined by the Speaker, in 

each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

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’’. 


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1 SEC. 2. REQUIREMENTS FOR PHYSICIAN SUPERVISION OF 

2 THERAPEUTIC HOSPITAL OUTPATIENT SERV3 ICES. 

4 (a) THERAPEUTIC HOSPITAL OUTPATIENT SERV5 ICES.— 

6 (1) SUPERVISION REQUIREMENTS.—Section 

7 1833 of the Social Security Act (42 U.S.C. 1395l) 

8 is amended by adding at the end the following new 

9 subsection: 

10 ‘‘(z) PHYSICIAN SUPERVISION REQUIREMENTS FOR

11 THERAPEUTIC HOSPITAL OUTPATIENT SERVICES.— 

12 ‘‘(1) GENERAL SUPERVISION FOR THERAPEUTIC

13 SERVICES.—Except as may be provided under para14 graph (2), insofar as the Secretary requires the su15 pervision by a physician or a non-physician practi16 tioner for payment for therapeutic hospital out17 patient services (as defined in paragraph (5)(A)) 

18 furnished under this part, such requirement shall be 

19 met if such services are furnished under the general 

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

21 physician or non-physician practitioner, as the case 

22 may be. 

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

24 COMPLEX MEDICAL SERVICES REQUIRING A DIRECT

25 LEVEL OF SUPERVISION.— 


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1 ‘‘(A) IN GENERAL.—Subject to the suc2 ceeding provisions of this paragraph, the Sec3 retary shall establish a process for the designa4 tion of therapeutic hospital outpatient services 

5 furnished under this part that, by reason of 

6 complexity or high risk, require— 

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

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

9 ‘‘(ii) direct supervision during the ini10 tiation of the service followed by general 

11 supervision for the remainder of the serv12 ice. 

13 ‘‘(B) CONSULTATION WITH CLINICAL EX14 PERTS.— 

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

16 established under subparagraph (A), before 

17 the designation of any therapeutic hospital 

18 outpatient service for which direct super19 vision may be required under this part, the 

20 Secretary shall consult with a panel of out21 side experts described in clause (ii) to ad22 vise the Secretary with respect to each 

23 such designation. 

24 ‘‘(ii) ADVISORY PANEL ON SUPER25 VISION OF THERAPEUTIC HOSPITAL OUTVerDate Mar 15 2010 21:05 Jul 24, 2013 Jkt 029200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H2801.IH H2801

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1 PATIENT SERVICES.—For purposes of 

2 clause (i), a panel of outside experts de3 scribed in this clause is a panel appointed 

4 by the Secretary, based on nominations 

5 submitted by hospital, rural health, and 

6 medical organizations representing physi7 cians, non-physician practitioners, and hos8 pital administrators, as the case may be, 

9 that meets the following requirements: 

10 ‘‘(I) COMPOSITION.—The panel 

11 shall be composed of at least 15 phy12 sicians and non-physician practi13 tioners who furnish therapeutic hos14 pital outpatient services for which 

15 payment is made under this part and 

16 who collectively represent the medical 

17 specialties that furnish such services, 

18 and of 4 hospital administrators of 

19 hospitals located in rural areas (as de20 fined in section 1886(d)(2)(D)) or 

21 critical access hospitals. 

22 ‘‘(II) PRACTICAL EXPERIENCE

23 REQUIRED FOR PHYSICIANS AND NON24 PHYSICIAN PRACTITIONERS.—During 

25 the 12-month period preceding apVerDate Mar 15 2010 21:05 Jul 24, 2013 Jkt 029200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H2801.IH H2801

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1 pointment to the panel by the Sec2 retary, each physician or non-physi3 cian practitioner described in sub4 clause (I) shall have furnished thera5 peutic hospital outpatient services for 

6 which payment was made under this 

7 part. 

8 ‘‘(III) MINIMUM RURAL REP9 RESENTATION REQUIREMENT FOR

10 PHYSICIANS AND NON-PHYSICIAN

11 PRACTITIONERS.—Not less than 50 

12 percent of the membership of the 

13 panel that is comprised of physicians 

14 and non-physician practitioners shall 

15 be physicians or non-physician practi16 tioners described in subclause (I) who 

17 practice in rural areas (as defined in 

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

19 such services in critical access hos20 pitals. 

21 ‘‘(iii) APPLICATION OF FACA.—The 

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

23 2 App.), other than section 14 of such Act, 

24 shall apply to the panel of outside experts 


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1 appointed by the Secretary under clause 

2 (ii). 

3 ‘‘(C) SPECIAL RULE FOR OUTPATIENT

4 CRITICAL ACCESS HOSPITAL SERVICES.—Inso5 far as a therapeutic outpatient hospital service 

6 that is an outpatient critical access hospital 

7 service is designated as requiring direct super8 vision under the process established under sub9 paragraph (A), the Secretary shall deem the 

10 critical access hospital furnishing that service 

11 as having met the requirement for direct super12 vision for that service if, when furnishing such 

13 service, the critical access hospital meets the 

14 standard for personnel required as a condition 

15 of participation under section 485.618(d) of 

16 title 42, Code of Federal Regulations (as in ef17 fect on the date of the enactment of this sub18 section). 

19 ‘‘(D) CONSIDERATION OF COMPLIANCE

20 BURDENS.—Under the process established 

21 under subparagraph (A), the Secretary shall 

22 take into account the impact on hospitals and 

23 critical access hospitals in complying with re24 quirements for direct supervision in the fur25 nishing of therapeutic hospital outpatient servVerDate Mar 15 2010 21:05 Jul 24, 2013 Jkt 029200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H2801.IH H2801

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1 ices, including hospital resources, availability of 

2 hospital-privileged physicians, specialty physi3 cians, and non-physician practitioners, and ad4 ministrative burdens. 

5 ‘‘(E) REQUIREMENT FOR NOTICE AND

6 COMMENT RULEMAKING.—Under the process 

7 established under subparagraph (A), the Sec8 retary shall only designate therapeutic hospital 

9 outpatient services requiring direct supervision 

10 under this part through proposed and final 

11 rulemaking that provides for public notice and 

12 opportunity for comment. 

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

14 in this subsection shall be construed as author15 izing the Secretary to apply or require any level 

16 of supervision other than general or direct su17 pervision with respect to the furnishing of 

18 therapeutic hospital outpatient services. 

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

20 The Secretary shall include in the proposed and final 

21 regulation for payment for hospital outpatient serv22 ices for 2015 under this part a list of initial thera23 peutic hospital outpatient services, if any, designated 

24 under the process established under paragraph 


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

2 part. 

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

4 PRACTITIONERS FOR CERTAIN HOSPITAL OUT5 PATIENT SERVICES PERMITTED.— 

6 ‘‘(A) IN GENERAL.—Subject to the suc7 ceeding provisions of this subsection, a non-phy8 sician practitioner may directly supervise the 

9 furnishing of— 

10 ‘‘(i) therapeutic hospital outpatient 

11 services under this part, including cardiac 

12 rehabilitation services (under section 

13 1861(eee)(1)), intensive cardiac rehabilita14 tion services (under section 1861(eee)(4)), 

15 and pulmonary rehabilitation services 

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

17 ‘‘(ii) those hospital outpatient diag18 nostic services (described in section 

19 1861(s)(2)(C)) that require direct super20 vision under the fee schedule established 

21 under section 1848. 

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

23 shall apply insofar as the non-physician practi24 tioner involved meets the following require25 ments: 


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1 ‘‘(i) SCOPE OF PRACTICE.—The non2 physician practitioner is acting within the 

3 scope of practice under State law applica4 ble to the practitioner. 

5 ‘‘(ii) ADDITIONAL REQUIREMENTS.— 

6 The non-physician practitioner meets such 

7 requirements as the Secretary may specify. 

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

9 ‘‘(A) THERAPEUTIC HOSPITAL OUT10 PATIENT SERVICES.—The term ‘therapeutic 

11 hospital outpatient services’ means hospital 

12 services described in section 1861(s)(2)(B) fur13 nished by a hospital or critical access hospital 

14 and includes— 

15 ‘‘(i) cardiac rehabilitation services and 

16 intensive cardiac rehabilitation services (as 

17 defined in paragraphs (1) and (4), respec18 tively, of section 1861(eee)); and 

19 ‘‘(ii) pulmonary rehabilitation services 

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

21 ‘‘(B) GENERAL SUPERVISION.— 

22 ‘‘(i) OVERALL DIRECTION AND CON23 TROL OF PHYSICIAN.—Subject to clause 

24 (ii), with respect to the furnishing of 

25 therapeutic hospital outpatient services for 


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1 which payment may be made under this 

2 part, the term ‘general supervision’ means 

3 such services that are furnished under the 

4 overall direction and control of a physician 

5 or non-physician practitioner, as the case 

6 may be. 

7 ‘‘(ii) PRESENCE NOT REQUIRED.—For 

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

9 physician or non-physician practitioner is 

10 not required during the performance of the 

11 procedure involved. 

12 ‘‘(C) DIRECT SUPERVISION.— 

13 ‘‘(i) PROVISION OF ASSISTANCE AND

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

15 respect to the furnishing of therapeutic 

16 hospital outpatient services for which pay17 ment may be made under this part, the 

18 term ‘direct supervision’ means that a phy19 sician or non-physician practitioner, as the 

20 case may be, is immediately available (in21 cluding by telephone or other means) to 

22 furnish assistance and direction through23 out the furnishing of such services. Such 

24 term includes, with respect to the fur25 nishing of a therapeutic hospital outpatient 


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1 service for which payment may be made 

2 under this part, direct supervision during 

3 the initiation of the service followed by 

4 general supervision for the remainder of 

5 the service (as described in paragraph 

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

7 ‘‘(ii) PRESENCE IN ROOM NOT RE8 QUIRED.—For purposes of clause (i), a 

9 physician or non-physician practitioner, as 

10 the case may be, is not required to be 

11 present in the room during the perform12 ance of the procedure involved or within 

13 any other physical boundary as long as the 

14 physician or non-physician practitioner, as 

15 the case may be, is immediately available. 

16 ‘‘(D) NON-PHYSICIAN PRACTITIONER DE17 FINED.—The term ‘non-physician practitioner’ 

18 means an individual who— 

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

20 practitioner, a clinical nurse specialist, a 

21 clinical social worker, a clinical psycholo22 gist, a certified nurse midwife, or a cer23 tified registered nurse anesthetist, and in24 cludes such other practitioners as the Sec25 retary may specify; and 


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

2 therapeutic outpatient hospital services, 

3 meets the requirements of paragraph 

4 (4)(B).’’. 

5 (2) CONFORMING AMENDMENT.—Section 

6 1861(eee)(2)(B) of the Social Security Act (42 

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

8 and a non-physician practitioner (as defined in sec9 tion 1833(z)(5)(D)) may supervise the furnishing of 

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

11 the case of items and services furnished under such 

12 a program in a hospital, such availability shall be 

13 presumed’’. 

14 (b) PROHIBITION ON RETROACTIVE ENFORCEMENT

15 OF REVISED INTERPRETATION.— 

16 (1) REPEAL OF REGULATORY CLARIFICA17 TION.—The restatement and clarification under the 

18 final rulemaking changes to the Medicare hospital 

19 outpatient prospective payment system and calendar 

20 year 2009 payment rates (published in the Federal 

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

22 68702 through 68704) with respect to requirements 

23 for direct supervision by physicians for therapeutic 

24 hospital outpatient services (as defined in paragraph 

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


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1 the Medicare program shall have no force or effect 

2 in law. 

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

4 access hospital that furnishes therapeutic hospital 

5 outpatient services during the period beginning on 

6 January 1, 2001, and ending on the later of Decem7 ber 31, 2014, or the date on which the final regula8 tion promulgated by the Secretary of Health and 

9 Human Services to carry out this Act takes effect, 

10 for which a claim for payment is made under part 

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

12 be subject to any civil or criminal action or penalty 

13 under Federal law for failure to meet supervision re14 quirements under the regulation described in para15 graph (1), under program manuals, or otherwise. 

16 (3) THERAPEUTIC HOSPITAL OUTPATIENT

17 SERVICES DEFINED.—In this subsection, the term 

18 ‘‘therapeutic hospital outpatient services’’ means 

19 medical and other health services furnished by a 

20 hospital or critical access hospital that are— 

21 (A) hospital services described in sub22 section (s)(2)(B) of section 1861 of the Social 

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

24 (B) cardiac rehabilitation services or inten25 sive cardiac rehabilitation services (as defined 


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1 in paragraphs (1) and (4), respectively, of sub2 section (eee) of such section); or 

3 (C) pulmonary rehabilitation services (as 

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

Æ 


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