(2)(A) as requiring direct supervision under this 
part. 
‘‘(4) DIRECT SUPERVISION BY NON-PHYSICIAN 
PRACTITIONERS
FOR
CERTAIN
HOSPITAL
OUT-
PATIENT SERVICES PERMITTED.— 
‘‘(A) IN
GENERAL.—Subject to the suc-
ceeding provisions of this subsection, a non-phy-
sician practitioner may directly supervise the 
furnishing of— 
‘‘(i) therapeutic hospital outpatient 
services under this part, including cardiac 
rehabilitation 
services 
(under 
section 
1861(eee)(1)), intensive cardiac rehabilita-
tion services (under section 1861(eee)(4)), 
and 
pulmonary 
rehabilitation 
services 
(under section 1861(fff)(1)); and 
‘‘(ii) those hospital outpatient diag-
nostic 
services 
(described 
in 
section 
1861(s)(2)(C)) that require direct super-
vision under the fee schedule established 
under section 1848. 
‘‘(B) REQUIREMENTS.—Subparagraph (A) 
shall apply insofar as the non-physician practi-
tioner involved meets the following require-
ments: 
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‘‘(i) SCOPE OF PRACTICE.—The non- 
physician practitioner is acting within the 
scope of practice under State law applica-
ble to the practitioner. 
‘‘(ii) ADDITIONAL
REQUIREMENTS.— 
The non-physician practitioner meets such 
requirements as the Secretary may specify. 
‘‘(5) DEFINITIONS.—In this subsection: 
‘‘(A) 
THERAPEUTIC
HOSPITAL
OUT-
PATIENT
SERVICES.—The term ‘therapeutic 
hospital outpatient services’ means hospital 
services described in section 1861(s)(2)(B) fur-
nished by a hospital or critical access hospital 
and includes— 
‘‘(i) cardiac rehabilitation services and 
intensive cardiac rehabilitation services (as 
defined in paragraphs (1) and (4), respec-
tively, of section 1861(eee)); and 
‘‘(ii) pulmonary rehabilitation services 
(as defined in section 1861(fff)(1)). 
‘‘(B) GENERAL SUPERVISION.— 
‘‘(i) OVERALL DIRECTION AND CON-
TROL
OF
PHYSICIAN.—Subject to clause 
(ii), with respect to the furnishing of 
therapeutic hospital outpatient services for 
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which payment may be made under this 
part, the term ‘general supervision’ means 
such services that are furnished under the 
overall direction and control of a physician 
or non-physician practitioner, as the case 
may be. 
‘‘(ii) PRESENCE NOT REQUIRED.—For 
purposes of clause (i), the presence of a 
physician or non-physician practitioner is 
not required during the performance of the 
procedure involved. 
‘‘(C) DIRECT SUPERVISION.— 
‘‘(i) PROVISION OF ASSISTANCE AND 
DIRECTION.—Subject to clause (ii), with 
respect to the furnishing of therapeutic 
hospital outpatient services for which pay-
ment may be made under this part, the 
term ‘direct supervision’ means that a phy-
sician or non-physician practitioner, as the 
case may be, is immediately available (in-
cluding by telephone or other means) to 
furnish assistance and direction through-
out the furnishing of such services. Such 
term includes, with respect to the fur-
nishing of a therapeutic hospital outpatient 
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service for which payment may be made 
under this part, direct supervision during 
the initiation of the service followed by 
general supervision for the remainder of 
the service (as described in paragraph 
(2)(A)(ii)). 
‘‘(ii) PRESENCE
IN
ROOM
NOT
RE-
QUIRED.—For purposes of clause (i), a 
physician or non-physician practitioner, as 
the case may be, is not required to be 
present in the room during the perform-
ance of the procedure involved or within 
any other physical boundary as long as the 
physician or non-physician practitioner, as 
the case may be, is immediately available. 
‘‘(D) NON-PHYSICIAN
PRACTITIONER
DE-
FINED.—The term ‘non-physician practitioner’ 
means an individual who— 
‘‘(i) is a physician assistant, a nurse 
practitioner, a clinical nurse specialist, a 
clinical social worker, a clinical psycholo-
gist, a certified nurse midwife, or a cer-
tified registered nurse anesthetist, and in-
cludes such other practitioners as the Sec-
retary may specify; and 
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‘‘(ii) with respect to the furnishing of 
therapeutic outpatient hospital services, 
meets the requirements of paragraph 
(4)(B).’’. 
(2) 
CONFORMING
AMENDMENT.—Section 
1861(eee)(2)(B) of the Social Security Act (42 
U.S.C. 1395x(eee)(2)(B)) is amended by inserting ‘‘, 
and a non-physician practitioner (as defined in sec-
tion 1833(z)(5)(D)) may supervise the furnishing of 
such items and services in the hospital’’ after ‘‘in 
the case of items and services furnished under such 
a program in a hospital, such availability shall be 
presumed’’. 
(b) PROHIBITION ON RETROACTIVE ENFORCEMENT 
OF REVISED INTERPRETATION.— 
(1) REPEAL
OF
REGULATORY
CLARIFICA-
TION.—The restatement and clarification under the 
final rulemaking changes to the Medicare hospital 
outpatient prospective payment system and calendar 
year 2009 payment rates (published in the Federal 
Register on November 18, 2008, 73 Fed. Reg. 
68702 through 68704) with respect to requirements 
for direct supervision by physicians for therapeutic 
hospital outpatient services (as defined in paragraph 
(3)) for purposes of payment for such services under 
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the Medicare program shall have no force or effect 
in law. 
(2) HOLD
HARMLESS.—A hospital or critical 
access hospital that furnishes therapeutic hospital 
outpatient services during the period beginning on 
January 1, 2001, and ending on the later of Decem-
ber 31, 2014, or the date on which the final regula-
tion promulgated by the Secretary of Health and 
Human Services to carry out this Act takes effect, 
for which a claim for payment is made under part 
B of title XVIII of the Social Security Act shall not 
be subject to any civil or criminal action or penalty 
under Federal law for failure to meet supervision re-
quirements under the regulation described in para-
graph (1), under program manuals, or otherwise. 
(3) 
THERAPEUTIC
HOSPITAL
OUTPATIENT 
SERVICES DEFINED.—In this subsection, the term 
‘‘therapeutic hospital outpatient services’’ means 
medical and other health services furnished by a 
hospital or critical access hospital that are— 
(A) hospital services described in sub-
section (s)(2)(B) of section 1861 of the Social 
Security Act (42 U.S.C. 1395x); 
(B) cardiac rehabilitation services or inten-
sive cardiac rehabilitation services (as defined 
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