A common question we get is, “can a PA or NP supervise hyperbaric treatments?” The answer is, probably. There are three elements to non-physician provider supervision of hyperbaric treatment:
According to Centers for Medicare and Medicaid Services (CMS), an NP or PA may supervise hyperbaric treatment. This rule is not specific to hyperbaric treatment; it applies to all hospital outpatient services. This is part of a hospital billing rule that requires direct physician supervision of hospital outpatient therapeutic services in order for a hospital to bill Medicare for those services. “Effective January 1, 2010 clinical psychologists, nurse practitioners, physician assistants, clinical nurse specialists, or certified nurse-midwives may provide direct supervision for hospital outpatient therapeutic services that they may perform themselves under state law and within their scope of practice and hospital-granted privileges (Ref: Federal Register/Vol. 74, No. 223/November 20, 2009/pg. 60579).” Medicare pays the PA or NP 85% of the physician rate for the professional services. Hospital payment rates are unaffected by PA or NP supervision. Insurance payers other than Medicare Administrative Contractors (MACs) may have their own rules regarding reimbursement for services performed by non-physician providers.
One of the MACs (Novitas Solutions, Inc.) currently has a requirement in their Local Coverage Determination on Hyperbaric Oxygen Therapy (L35021) stating, “Limited license providers performing hyperbaric medicine services must have an unlimited licensed physician immediately available to render assistance if needed.” CMS considers an NP or PA to be a limited license provider. Another MAC (Noridian Healthcare Solutions) has proposed a Draft Local Coverage Determination on Hyperbaric Oxygen Therapy containing identical language. At the time of this writing, that draft has not become a Noridian active policy.
Treatment of the hyperbaric patient must be within the scope of practice of the PA or NP. The scope of practice differs for PAs and NPs and it varies state by state. It is unlikely for any state to specify hyperbaric treatment in the scope of practice of either a PA or NP.
Regarding PAs, hyperbaric treatment should be within the PA scope of practice because of the broad nature of PA training. A PA is truly a physician extender, and as such will always work under the supervision of a physician. The specific requirements of the PA/supervising physician relationship are dictated by the PA scope of practice.
Regarding NPs, there are different kinds of NP certification; and each focuses on a specific population (e.g. Geriatric Nurse Practitioner training focuses on care of the elderly; Women’s Health Nurse Practitioner training focuses on care of females; Family Nurse Practitioner training focuses on both genders and all age groups). Therefore hyperbaric treatment (more specifically the population being treated) may fall into the scope of some NPs and not others. In some states, an NP can practice independently with no mandated physician relationship. In most states, an NP must have a collaborative agreement with a physician. Some states require the collaborating physician to meet with the NP or periodically audit a portion of the NP’s charts. Some states require an NP’s prescriptive authority to be delegated by a physician. Typically, the NP is not required to be employed by the collaborative/delegating physician; and the collaborative/delegating physician does not assume responsibility for patient care performed by the NP.
The PA or NP must have privileges (granted by the hospital) to perform hyperbaric treatment, just as any physician must. The hospital medical staff determines if a physician, PA, or NP is eligible for privileges; and this determination should be based on adequate training in hyperbaric medicine. The Undersea & Hyperbaric Medical Society (UHMS) and the American College of Hyperbaric Medicine (ACHM) have guidelines for hyperbaric physician/provider training. A Medicare Administrative Contractor may have training recommendations or requirements in its Local Coverage Determination for hyperbaric oxygen therapy.
Robert B. Sheffield, BA, CHT
Director of Education
International ATMO, Inc.