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Re: SignaturesFrom: ainsron (ainsron@sbcglobal.net)Tue Aug 7 09:42:12 2007
What the Medicare (CMS) interpretive guidelines require is that for all Medicare or Medicaid patients cared for by a CNM be admitted under the care of an MD or DO. Each state can have stricter requirements, but in California, the DHS guidelines are similar: "CMS hospital regulations do permit licensed practitioners (e.g., nurse practitioners, Pas, etc), as allowed by the State, to admit patients to a hospital, and CMS does not require these practitioners be employed by a MD/DO. However, CMS regulations do require that Medicare and Medicaid patients admitted by these practitioners be under the care of an MD/DO. Evidence of being under the care of an MD/DO must be in the patient's medical record. If a hospital allows these practitioners to admit and care for patients, as allowed by State law, the governing body and medical staff would have to establish policies and bylaws to ensure that the requirements of 42 CFR §482 are met. Midwife Patients 42 CFR §482..1(a) (5) states "Section 1905(a) of the Act provides that 'medical assistance' (Medicaid) payments may be applied to various hospital services. Regulations interpreting those provisions specify that hospitals receiving payment under Medicaid must meet the requirements for participation in Medicare (except in the case of medical supervision of nurse midwife services. (See §'440. 10 and 440.165 of this chapter). " Midwives are not specified in 42 CFR §482.12(c)(1). §482.1(a)(5), when taken with this requirement, (42 CPR §482.12(c)(2)) means that in a state that permits midwives to admit patients (and in accordance with hospital policy and practitioner privileges), CMS requires ONLY Medicare patients of a midwife be under the care of a doctor of medicine or osteopathy. CMS DOES NOT require Medicaid or other non-Medicare patients admitted by a midwife be under the care of a doctor of medicine or osteopathy." I would assume then that each hospital must produce evidence that the physician is truly "caring for" each CNM patient, by countersigning something. However, it is onerous and virtually impossible to counter-sign and date each CNM order within the 48 hours required by hospital policies designed to meet other CMS timeliness guidelines. Ronald E. Ainsworth, MD, FACOG -----Original Message----- From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Marie Harkins Sent: Monday, August 06, 2007 7:56 PM To: Multiple recipients of list OB-GYN-L Subject: Re: Signatures I believe that some of the rules may be determined by a combination of state regulations and hospital bylaws. In NY, Liscenced Midwives have prescriptive privledges and do not need medication orders or scripts cosigned. At our hospital, some of the paperwork is also dictated by staff position and type of hospital privileges. Midwives used to be considered affiliate staff until we got admitting privileges a few years ago. With admitting privileges, patients were then able to be admitted under our names instead of which ever physician from our group was on call. This also eliminated the need for them to cosign H&Ps and some of the other hospital paperwork. I think that our docs are happy to be spending less time down in medical records and it is more reflective of the way that we really practice. Marie Harkins, CNM Ithaca, NY
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