II 

112TH CONGRESS 

1ST SESSION S. 778 

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 

APRIL 8, 2011 

Mr. MORAN 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 COMPRISED OF PHYSI23 CIANS AND NON-PHYSICIAN PRACTI24 TIONERS SERVING RURAL AND OTHER

25 AREAS.—For purposes of clause (i), a 


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1 panel of outside experts described in this 

2 clause is a panel appointed by the Sec3 retary, based on nominations submitted by 

4 hospital, rural health, and medical organi5 zations representing physicians or non-phy6 sician practitioners, as the case may be, 

7 that meets the following requirements: 

8 ‘‘(I) COMPOSITION.—The panel 

9 shall be composed of at least 15 phy10 sicians and non-physician practi11 tioners who furnish therapeutic hos12 pital outpatient services for which 

13 payment is made under this part and 

14 who collectively represent the medical 

15 specialties that furnish such services. 

16 ‘‘(II) PRACTICAL EXPERIENCE.— 

17 During the 12-month period preceding 

18 appointment to the panel by the Sec19 retary, each physician or non-physi20 cian practitioner described in sub21 clause (I) shall have furnished thera22 peutic hospital outpatient services for 

23 which payment was made under this 

24 part. 


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1 ‘‘(III) MINIMUM RURAL REP2 RESENTATION REQUIREMENT.—Not 

3 less than 50 percent of the member4 ship of the panel shall be physicians 

5 or non-physician practitioners de6 scribed in subclause (I) who practice 

7 in rural areas (as defined in section 

8 1886(d)(2)(D)) or who furnish such 

9 services in critical access hospitals. 

10 ‘‘(iii) APPLICATION OF FACA.—The 

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

12 2 App.), other than section 14 of such Act, 

13 shall apply to the panel of outside experts 

14 appointed by the Secretary under clause 

15 (ii). 

16 ‘‘(C) SPECIAL RULE FOR OUTPATIENT

17 CRITICAL ACCESS HOSPITAL SERVICES.—Inso18 far as a therapeutic outpatient hospital service 

19 that is an outpatient critical access hospital 

20 service is designated as requiring direct super21 vision under the process established under sub22 paragraph (A), the Secretary shall deem the 

23 critical access hospital furnishing that service 

24 as having met the requirement for direct super25 vision for that service if, when furnishing such 


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1 service, the critical access hospital meets the 

2 standard for personnel required as a condition 

3 of participation under section 485.618(d) of 

4 title 42, Code of Federal Regulations (as in ef5 fect on the date of the enactment of this sub6 section). 

7 ‘‘(D) CONSIDERATION OF COMPLIANCE

8 BURDENS.—Under the process established 

9 under subparagraph (A), the Secretary shall 

10 take into account the impact on hospitals and 

11 critical access hospitals in complying with re12 quirements for direct supervision in the fur13 nishing of therapeutic hospital outpatient serv14 ices, including hospital resources, availability of 

15 hospital-privileged physicians, specialty physi16 cians, and non-physician practitioners, and ad17 ministrative burdens. 

18 ‘‘(E) REQUIREMENT FOR NOTICE AND

19 COMMENT RULEMAKING.—Under the process 

20 established under subparagraph (A), the Sec21 retary shall only designate therapeutic hospital 

22 outpatient services requiring direct supervision 

23 under this part through proposed and final 

24 rulemaking that provides for public notice and 

25 opportunity for comment. 


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

2 in this subsection shall be construed as author3 izing the Secretary to apply or require any level 

4 of supervision other than general or direct su5 pervision with respect to the furnishing of 

6 therapeutic hospital outpatient services. 

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

8 The Secretary shall include in the proposed and final 

9 regulation for payment for hospital outpatient serv10 ices for 2012 under this part a list of initial thera11 peutic hospital outpatient services, if any, designated 

12 under the process established under paragraph 

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

14 part. 

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

16 PRACTITIONERS FOR CERTAIN HOSPITAL OUT17 PATIENT SERVICES PERMITTED.— 

18 ‘‘(A) IN GENERAL.—Subject to the suc19 ceeding provisions of this subsection, a non-phy20 sician practitioner may directly supervise the 

21 furnishing of— 

22 ‘‘(i) therapeutic hospital outpatient 

23 services under this part, including cardiac 

24 rehabilitation services (under section 

25 1861(eee)(1)), intensive cardiac rehabilitaVerDate Mar 15 2010 22:09 Apr 12, 2011 Jkt 099200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S778.IS S778

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1 tion services (under section 1861(eee)(4)), 

2 and pulmonary rehabilitation services 

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

4 ‘‘(ii) those hospital outpatient diag5 nostic services (described in section 

6 1861(s)(2)(C)) that require direct super7 vision under the fee schedule established 

8 under section 1848. 

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

10 shall apply insofar as the non-physician practi11 tioner involved meets the following require12 ments: 

13 ‘‘(i) SCOPE OF PRACTICE.—The non14 physician practitioner is acting within the 

15 scope of practice under State law applica16 ble to the practitioner. 

17 ‘‘(ii) ADDITIONAL REQUIREMENTS.— 

18 The non-physician practitioner meets such 

19 requirements as the Secretary may specify. 

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

21 ‘‘(A) THERAPEUTIC HOSPITAL OUT22 PATIENT SERVICES.—The term ‘therapeutic 

23 hospital outpatient services’ means hospital 

24 services described in section 1861(s)(2)(B) furVerDate Mar 15 2010 22:09 Apr 12, 2011 Jkt 099200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S778.IS S778

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1 nished by a hospital or critical access hospital 

2 and includes— 

3 ‘‘(i) cardiac rehabilitation services and 

4 intensive cardiac rehabilitation services (as 

5 defined in paragraphs (1) and (4), respec6 tively, of section 1861(eee)); and 

7 ‘‘(ii) pulmonary rehabilitation services 

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

9 ‘‘(B) GENERAL SUPERVISION.— 

10 ‘‘(i) OVERALL DIRECTION AND CON11 TROL OF PHYSICIAN.—Subject to clause 

12 (ii), with respect to the furnishing of 

13 therapeutic hospital outpatient services for 

14 which payment may be made under this 

15 part, the term ‘general supervision’ means 

16 such services that are furnished under the 

17 overall direction and control of a physician 

18 or non-physician practitioner, as the case 

19 may be. 

20 ‘‘(ii) PRESENCE NOT REQUIRED.—For 

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

22 physician or non-physician practitioner is 

23 not required during the performance of the 

24 procedure involved. 

25 ‘‘(C) DIRECT SUPERVISION.— 


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1 ‘‘(i) PROVISION OF ASSISTANCE AND

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

3 respect to the furnishing of therapeutic 

4 hospital outpatient services for which pay5 ment may be made under this part, the 

6 term ‘direct supervision’ means that a phy7 sician or non-physician practitioner, as the 

8 case may be, is immediately available (in9 cluding by telephone or other means) to 

10 furnish assistance and direction through11 out the furnishing of such services, wheth12 er such services are furnished in the hos13 pital, in an on-campus department of the 

14 hospital, or an off-campus provider-based 

15 department of the hospital. Such term in16 cludes, with respect to the furnishing of a 

17 therapeutic hospital outpatient service for 

18 which payment may be made under this 

19 part, direct supervision during the initi20 ation of the service followed by general su21 pervision for the remainder of the service 

22 (as described in paragraph (2)(A)(ii)). 

23 ‘‘(ii) PRESENCE IN ROOM NOT RE24 QUIRED.—For purposes of clause (i), a 

25 physician or non-physician practitioner, as 


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1 the case may be, is not required to be 

2 present in the room during the perform3 ance of the procedure involved. 

4 ‘‘(D) NON-PHYSICIAN PRACTITIONER DE5 FINED.—The term ‘non-physician practitioner’ 

6 means an individual who— 

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

8 practitioner, a clinical nurse specialist, a 

9 clinical social worker, a clinical psycholo10 gist, a certified nurse midwife, or a cer11 tified registered nurse anesthetist, and in12 cludes such other practitioners as the Sec13 retary may specify; and 

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

15 therapeutic outpatient hospital services, 

16 meets the requirements of paragraph 

17 (4)(B).’’. 

18 (2) CONFORMING AMENDMENT.—Section 

19 1861(eee)(2)(B) of the Social Security Act (42 

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

21 and a non-physician practitioner (as defined in sec22 tion 1833(z)(5)(D)) may supervise the furnishing of 

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

24 the case of items and services furnished under such 


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1 a program in a hospital, such availability shall be 

2 presumed’’. 

3 (b) PROHIBITION ON RETROACTIVE ENFORCEMENT

4 OF REVISED INTERPRETATION.— 

5 (1) REPEAL OF REGULATORY CLARIFICA6 TION.—The restatement and clarification under the 

7 final rulemaking changes to the Medicare hospital 

8 outpatient prospective payment system and calendar 

9 year 2009 payment rates (published in the Federal 

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

11 68702 through 68704) with respect to requirements 

12 for direct supervision by physicians for therapeutic 

13 hospital outpatient services (as defined in paragraph 

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

15 the Medicare program shall have no force or effect 

16 in law. 

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

18 access hospital that furnishes therapeutic hospital 

19 outpatient services during the period beginning on 

20 January 1, 2001, and ending on the later of Decem21 ber 31, 2012, or the date on which the final regula22 tion promulgated by the Secretary of Health and 

23 Human Services to carry out this Act takes effect, 

24 for which a claim for payment is made under part 

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


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1 be subject to any civil or criminal action or penalty 

2 under Federal law for failure to meet supervision re3 quirements under the regulation described in para4 graph (1), under program manuals, or otherwise. 

5 (3) THERAPEUTIC HOSPITAL OUTPATIENT

6 SERVICES DEFINED.—In this subsection, the term 

7 ‘‘therapeutic hospital outpatient services’’ means 

8 medical and other health services furnished by a 

9 hospital or critical access hospital that are— 

10 (A) hospital services described in sub11 section (s)(2)(B) of section 1861 of the Social 

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

13 (B) cardiac rehabilitation services or inten14 sive cardiac rehabilitation services (as defined 

15 in paragraphs (1) and (4), respectively, of sub16 section (eee) of such section); or 

17 (C) pulmonary rehabilitation services (as 

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

Æ 


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