how licensure affects the applicable codes for healthcare projects

Flad Architects of 2 Flad Code Forum Notes : 04 December 2015

Flad Code Forum Notes 04 December 2015 1. Code Forums

a. Notes of past code forums are posted at : i. Flad Home Page / Resources / Codes / Forums / Year / Date of Forum.

b. This Code Forum will Discuss : i. How Licensure Affects the Applicable Codes for Healthcare Projects

c. Additional information is contained in attached power point slides: PP-pages. How Licensure Affects the Applicable Codes for Healthcare Projects

Refer to PP-01 through PP-63 2. References

a. NFPA 101 Life Safety Code - 2000 edition = LSC b. International Building Code - 2012 edition = IBC

3. Questions to Ask our (HC) Clients : PP-03 a. All Flad project teams should ask these (2) questions of all of our clients, especially our

healthcare clients. Non-healthcare occupancies (e.g. business) can be part of a licensed healthcare facility depending on the licensure requirements of the state that the facility is located.

4. Who Regulates Hospitals? : PP-07 - PP-08 a. Federal : see CMS requirements (2000 LSC) b. State : see licensure requirements (Codes : vary by state) c. Local : see municipality requirements (e.g. Fire Marshalls may review plans/inspect

projects) 5. History of HC Regulation & Codes : PP-09 - PP-10

a. LSC editions : 1967, 1985, & 2000 (2012 adopted soon?) b. CMS enforces Conditions of Participation & Conditions for Coverage for a myriad of

healthcare-related facilities. 6. History of CMS : PP-09 - PP-14

a. CMS has evolved from HEW, HCFA, and HHS. b. CMS Responsibilities c. CMS Regional Offices

7. State Agencies (SA) : PP-16 – PP-25 a. Legislative Hierarchy

i. Licensure requirements start with statutes (laws) that are very broad and general in nature.

ii. Statutes are supplemented with regulations & rules that are more detailed. iii. Finally, policy & procedures explain how the regulations & rules are enforced.

b. Wisconsin DHS Regulatory Guidelines : Federal, SOM, & WI statutes i. Chapter 50 : Uniform Licensure ii. Chapter 150 : Regulation of Health Services iii. Chapter DHS 124 : Hospitals

c. DHS Plan Review Process i. “T18” reference is Title XVIII (18) of the Social Security Act which established

regulations for Medicare. ii. “T19” reference is Title XIV (19) of the Social Security Act which established

regulations for Medicaid. 8. Hospital Licensure : PP-27 – PP-30

a. Hospitals are (1) of (4) licensed healthcare facilities in Wisconsin. b. DHS definition of Hospitals : different than occupancy definitions per LSC, IBC, & CMS.

Flad Architects of 2 Flad Code Forum Notes : 04 December 2015

9. Licensure vs. Occupancy : PP-32 – PP-39 a. HC Occupancy (LSC)

i. Does NOT identify outpatients ii. DOES identify number of “inpatients” iii. DOES identify duration of use (24-hours)

b. HC Occupancy (IBC) i. Does NOT identify inpatients vs. outpatients ii. Does NOT identify number of “care recipients” iii. Does NOT identify duration of care (24-hours).

10. Survey & Certification Letters (S&C) : PP-41 - PP-50 a. S&C letters aid in code enforcement for surveyors and certification.

11. Questions to Ask our (HC) Clients : PP-52 - PP-58 a. Transmittal A-03-030 should be provided to (HC) clients to determine if their facility or

project meets the criteria to be “provider-based.” b. Why is this an issue? Money

i. Clinic facility fees (CFF) allow hospital-affiliated clinics to charge additional fees (hospital facility fees) to any service provided in their clinics.

c. National Provider Number : Unique health identifier for health care providers for use in the health care system when billing to Medicare/Medicare.

12. Project Example : PP-60 - PP-62 a. MOB added to Hospital

i. Initial design designed to comply with IBC only & not LSC or HC Licensure ii. Years later G Hospital purchases MOB and wants to bill services to their CMS

provider number. (1) Facility assumed it was a simple “change” to their state hospital license. (2) Review of MOB by state licensing agency identified (2) licensure deficiencies :

(a) 2-story vertical opening open to the corridors – not allowed by LSC. (b) Plenum mechanical returns – not allowed per Guidelines.

T:\twyatt\Code\Code Forums\2015 1204\2015 1204 Code Forum Notes.docx

F L A D C O D E F O R U M

How Licensure Affects the Applicable

Codes for Healthcare Projects

12/04/2015 Flad Code Forum 1

Questions to Ask our (HC) Clients

• Q1. Is <Insert Project Here> currently a licensed health care facility by the State Health Department?

• Q2. Is there a desire, currently or in the future, for <Insert Project Here> to house individuals / groups / practices that will bill healthcare services under your organization’s CMS provider number ?


NO

(Positive)

YES

(Positive)

Does Not

Know


T H A N K Y O U F O R

AT T E N D I N G


O U T L I N E

• Who Regulates Hospitals?

– Fed/State/Local

– History

• CMS (Federal)

– History

– Responsibilities

• State Agencies (SA)

• Hospitals– HC Facility Types

• Licensure vs. Occupancy– Licensure Definitions

– Code Definitions

• CMS S&C Letters– LSC related

– Physical Environment

• ?s to Ask (HC) Clients– CMS Provider Number

– CMS Billing Clarification

• Project Example


Who Regulates Hospitals ?


Who Regulates Hospitals ?

• Hospitals must comply with state licensure rules

• Federal Certification for Medicare/Medicaid by …– CMS/State Agency (SA) or

– Private accreditation agency (Joint Commission, HFPA, DNV)


AHJs - Top to Bottom

• Federal : CMS– Centers for Medicare & Medicaid Services

– Codes• 2000 NFPA 101 Life Safety Code (LSC)

• State : Wisconsin– Department of Health Services (DHS)

– Codes• 2000 NFPA 101 Life Safety Code (LSC)

• WI Commercial Building Code (WCBC = 2009 IBC)

• Local : Municipality – A city, village, town or local board of health

– Fire Marshall / Fire Department


History of HC Regulation & Codes

• 1946 : Hospital Survey and Construction Act (Hill Burton Act)– Code : Building Exits Code (pre-NFPA 101 LSC)

• 1965 : Social Security Act (1970) – Title XVIII (Medicare)

• Part A : provides hospital insurance for the aged,

• Part B : provides supplementary medical insurance

– Title XIX (Medicaid) : provides for the states to finance health care for individuals

– Social Security Administration (SSA) administers it

• 1971 : CMS (HCFA) adopts the 1967 NFPA 101 LSC

• 1987 : CMS (HCFA) adopts the 1985 NFPA 101 LSC

• 2003 (3/11/03) : CMS adopts the 2000 NFPA 101 LSC

• 2011: CMS announces adoption of the 2012 NFPA 101 LSC


CMS : Conditions of Participation (CoPs)

and Conditions for Coverage (CfCs)

• Medicare & Medicaid

– Compliance with the

2000 NFPA 101 Life

Safety Code (LSC)

• Health and safety

standards for the

following HC

organizations

• Ambulatory Surgical Centers (ASCs)

• Community Mental Health Centers (CMHCs)

• Comprehensive Outpatient Rehabilitation Facilities (CORFs)

• Critical Access Hospitals (CAHs)

• End-Stage Renal Disease Facilities

• Federally Qualified Health Centers

• Home Health Agencies

• Hospices

• Hospitals

• Hospital Swing Beds

• Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)

• Organ Procurement Organizations (OPOs)

• Portable X-Ray Suppliers

• Programs for All-Inclusive Care for the Elderly Organizations (PACE)

• Clinics, Rehabilitation Agencies, and Public Health Agencies– Providers of Outpatient Physical Therapy and Speech-Language

• Pathology Services

• Psychiatric Hospitals

• Religious Nonmedical Health Care Institutions

• Rural Health Clinics

• Long Term Care Facilities

• Transplant Centers


CMS (Federal)


History of CMS

– 1953-1979 : HEW established• Department of Health, Education & Welfare

• 1977-2001 : HCFA established– Health Care Financing Administration

– Coordination of Medicare and Medicaid

– SSA

» Enroll beneficiaries into Medicare

» Processing premium payments

– 1979 - Current : HHS (renamed from HEW)• Department of Health and Human Services

• 1996 : SSA (Social Security Administration) – Removed from HHS

• 2001 - Present : CMS (renamed from HCFA)– Centers for Medicare & Medicaid Services


CMS Responsibilities

• Administers the Medicare program (Federal)

• Partners with State governments to administer– Medicaid (State)

– SCHIP• State Children's Health Insurance Program

• Other Responsibilities– Administrative simplification standards for HIPAA

• Health Insurance Portability and Accountability Act of 1996

– Quality standards for Long-Term Care Facilities (Nursing homes)

– CLIA• Clinical Laboratory Improvement Amendments

– Oversight of HealthCare.gov


CMS Regional Offices (RO)

• Region I – Boston

• Connecticut, Massachusetts, Maine, New

Hampshire, Rhode Island and Vermont.

• Region II – New York City

• New York, New Jersey, Virgin Islands and

Puerto Rico.

• Region III – Philadelphia

• Delaware, Maryland, Pennsylvania,

Virginia, West Virginia and DC

• Region IV – Atlanta

• Alabama, Florida, Georgia, Kentucky,

Mississippi, North Carolina, South Carolina

and Tennessee.

• Region V – Chicago

• Illinois, Indiana, Michigan, Minnesota,

Ohio and Wisconsin.

• Region VI - Dallas• Arkansas, Louisiana, New Mexico,

Oklahoma, Texas

• Region VII – Kansas City • Iowa, Kansas, Missouri, Nebraska

• Region VIII – Denver • Colorado, Montana, North Dakota,

South Dakota, Utah, Wyoming

• Region IX – San Francisco • Arizona, California, Hawaii, Nevada,

Pacific Territories

• Region X – Seattle • Alaska, Idaho, Oregon, Washington


State Agencies (SA)


Legislative Hierarchy

• Statutes– Formal written enactment of a legislative authority.

– Command or prohibit something, or declare policy.

• Regulations– A written order containing rules having the force of law.

– Prescribed by authority, especially to regulate conduct.

• Rules– Details of how a statute or a regulation is put into effect.

– Governs conduct, action, procedure, or arrangement.

• Policy & Procedures– Identifies the responsibility, authority, and accountability

of individuals within the framework of the department.


WI DHS Regulatory Guidelines

• Code of Federal Regulations– 42 CFR 482

• For general and specialty hospitals

– 42 CFR 485• Conditions of Participation (CoP) for Hospitals

• State Operations Manual (SOM)– Appendices A, AA, T, V and W

– Different hospital types

• Wisconsin Statutes– Chapter 50 : Uniform Licensure

– Chapter 150 : Regulations of Health Services

– Chapter DHS 124 : Hospitals• Wisconsin Administrative Code


Licensed WI Health Care (HC) Facility Types


Chapter DHS 124


Chapter DHS 124 : HOSPITALS

• Subchapter I — General

• Subchapter II — Management

• Subchapter III — Medical Staff

• Subchapter IV — Services

• Subchapter V — Physical Environment

• Subchapter VI — Critical Access Hospitals


Subchapter V — Physical Environment

• DHS 124.27 General requirements and definitions.

• DHS 124.28 Fire protection.

• DHS 124.29 Plans for new construction or remodeling.

• DHS 124.30 Review for compliance with this chapter and the state building code.

• DHS 124.31 Fees for plan reviews.

• DHS 124.32 Patient rooms - general.

• DHS 124.33 Isolation.

• DHS 124.34 Patient care areas.

• DHS 124.35 Additional requirements for particular patient care areas.

• DHS 124.36 Other physical environment.



Title XVIII (18) of the Social Security Act established regulations for Medicare


Title XVIII (18) of the Social Security Act established regulations for Medicare

Title XIX (19) of the Social Security Act established regulations for Medicaid

HOSPITALS


Licensed WI Health Care (HC) Facility Types

• CARE AND SERVICE RESIDENTIAL FACILITIES– Adult family home

– Community−based residential facility

– Home health agency

– Nursing home

– Residential care apartment complex

• HOSPITALS

• RURAL MEDICAL CENTERS

• HOSPICES


Other occupancies physically attached to a HC Facility Type

Hospitals : DHS (WI)

• 50.33 Definitions. – (a) “Hospital” means any building, structure, institution or

place devoted primarily to the maintenance and operation of facilities for the diagnosis, treatment of and medical or surgical care for 3 or more nonrelated individuals hereinafter designated patients, suffering from illness, disease, injury or disability, whether physical or mental, and including pregnancy and regularly making available at least clinical laboratory services, and diagnosQc X−ray services and treatment facilities for surgery, or obstetrical care, or other definitive medical treatment.

– (b) “Hospital” may include, but not in limitation thereof by enumeration, related facilities such as outpatient facilities, nurses’, interns’ and residents’ quarters, training facilities and central service facilities operated in connection with hospital.


Hospitals : DHS (WI)

• Chapter DHS 124 - HOSPITALS

– Construction/Remodeling for Health Care Facilities

• DHS 124.28 Fire protection.

– (1) BASIC RESPONSIBILITY. The hospital shall provide fire protection adequate to ensure the safety of patients, staff and others on the hospital’s premises. Necessary safeguards such as extinguishers, sprinkling and detection devices, fire and smoke barriers, and ventilation control barriers shall be installed to ensure rapid and effective fire and smoke control.

– (2) LIFE SAFETY CODE. Facilities shall meet the applicable provisions of the 2000 edition of the Life Safety Code (LSC)


Hospitals : CMS

• A hospital is an institution primarily engaged in providing, by or under the supervision of physicians, inpatient diagnostic and therapeutic services or rehabilitation services.

• The State Survey Agency (e.g. State of Wisconsin) evaluates and certifies each participating hospital as a whole for compliance with the Medicare requirements and certifies it as a single provider institution.

• Under the Medicare provider-based rules it is possible for ‘one' hospital to have multiple inpatient campuses and outpatient locations.

• It is not permissible to certify only part of a participating hospital.

• Not considered parts of the hospital and are not to be included in the evaluation of the hospital's compliance:– Components appropriately certified

as other kinds of providers or suppliers :• Skilled Nursing Facility

• Nursing Facility

• Home Health Agency

• Rural Health Clinic

• Hospice

• Excluded residential, custodial, and non-service units not meeting certain definitions in the Social Security Act; and,

– Physician offices located in space owned by the hospital but notfunctioning as hospital outpatient services departments


Licensure vs. Occupancy


Licensure

• The State of Wisconsin (Department of Health Services (DHS), Division of Quality Assurance (DQA), Office of Plan Review and Inspection (OPRI)) reviews construction plans, surveys the finished project, and licenses HC facilities (e.g. Hospitals).

• By doing this, the State of Wisconsin certifies that state-licensed HC facilities meet the requirements of CMS participation. The definition of what constitutes a state-licensed HC facilities is determined on a state-by-state basis.

• The State of Wisconsin defines a Hospital and includes “related facilities such as outpatient facilities, nurses’, interns’ and residents’ quarters, training facilities and central service facilities operated in connection with hospitals.”


Health Care Occupancy (LSC 2012)

• 3.3.142 Hospital. A building or portion thereof used on a 24-hour basis for the medical, psychiatric, obstetrical, or surgical care of four or more inpatients.

• 18.1.1.1.4 The term hospital, wherever used in this Code, shall include general hospitals, psychiatric hospitals, and specialty hospitals.

– Does NOT identify outpatients

– DOES identify number of “inpatients”

– DOES identify duration of use (24-hours)



18.1.3.4 Contiguous Non-Health Care Occupancies.

18.1.3.4.1 *Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies, but are primarily intended to provide outpatient services, shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by construction having a minimum 2-hour fire resistance rating, and the facility is not intended to provide services simultaneously for four or more inpatients who are incapable of self preservation.

18.1.3.4.2 Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies shall be permitted to be used for diagnostic and treatment services of inpatients who are capable of self-preservation.



18.1.3.3* Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet both of the following conditions:

(1) They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self-preservation.

(2) They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8.

Chapter 8 : 8.3 Fire Barriers

A.18.1.3.3 Doctors' offices and treatment and diagnostic facilities that are intended solely for outpatient care and are physically separated from facilities for the treatment or care of inpatients, but that are otherwise associated with the management of an institution, might be classified as business occupancies rather than health care occupancies. Facilities that do not provide housing for patients on a 24-hour basis are required to be classified as other than health care occupancies per 18.1.1.1.7, except where services are provided routinely to four or more inpatients who are incapable of self- preservation.


Occupancy (IBC 2012)

• HOSPITALS AND PSYCHIATRIC HOSPITALS.

Facilities that provide care or treatment for

the medical, psychiatric, obstetrical, or

surgical treatment of care recipients that are

incapable of self-preservation.

– Does NOT identify inpatients vs. outpatients

– Does NOT identify number of “care recipients”

– Does NOT identify duration of care (24-hours)



• 308.4 Institutional Group I-2.

– This occupancy shall include buildings and structures used for medical care on a 24-hour basis for more than fivepersons who are incapable of self-preservation.

• This group shall include, but not be limited to, the following:

– Foster care facilities

– Detoxification facilities

– Hospitals

– Nursing homes

– Psychiatric hospitals



• MEDICAL CARE– Care involving medical or surgical procedures, nursing or for

psychiatric purposes.

• 24-HOUR CARE– The actual time that a person is an occupant within a facility for

the purpose of receiving care.

– It shall not include a facility that is open for 24 hours and is capable of providing care to someone visiting the facility during any segment of the 24 hours.

• INCAPABLE OF SELF-PRESERVATION– Persons because of age, physical limitations, mental limitations,

chemical dependency, or medical treatment who cannot respond as an individual to an emergency situation.


I-2 Occupancy? (IBC 2012)

• Dentist Office

– Medical Care : YES

– 24-Hour Basis : NO

– >(5) persons : YES

– Incapable of self-

preservation : YES

• Bar

– Medical Care : NO

– 24-Hour Basis : YES

– >(5) persons : YES

– Incapable of self-

preservation : ???


CMS S&C Letters


Survey & Certification Letters

• Purpose : intended to aid in code enforcement

for surveyors and certification

• Difference between compliance with CMS and

state licensure requirements


CMS : Policy/Memos to States/Regionshttps://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SUrveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html

As of today, there are (653) S&C letters.


CMS : Policy/Memos to States/Regionshttps://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SUrveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html

Filter using “LSC” and there are (18) applicable S&C letters.


CMS : S&C’s - Physical Environment

• Categorical Waiver for Power Strips Use in Patient Care Areas Various (14-46-LSC)

• Information for Applications to Extend the Due Date for the Installation of Automatic Sprinkler Systems in Existing Nursing Homes (14-29-L)

• Publication of Notice of Proposed Rulemaking (NPRM) for Fire Safety Requirements – Informational Only (14-21- LSC)

• Citations at F Tag 454 – 42 CFR §483.70 Physical Environment, §483.70(a) Life Safety from Fire (14-03-NH/LSC)

• 2000 Edition National Fire Protection Association (NFPA) 101® Life Safety Code (LSC) Waivers (13-58-LSC)

• Enforcement Actions - Installation of Automatic Sprinkler Systems in Nursing Homes - August 13, 2013 Deadline (13-55-LSC)

• Compliance with the Life Safety Code (LSC) in End Stage Renal Disease (ESRD) Facilities (13-47-LSC/ESRD)

• Relative Humidity (RH): Waiver of Life Safety Code (LSC) Anesthetizing Location Requirements; Discussion of Ambulatory Surgical Center (ASC) Operating Room Requirements (13-25-LSC & ASC)

• Life Safety Code (LSC) Short Form Survey for Nursing Homes – Limited Option (13-22-NH)

• Instructions Concerning Waivers of Specific Requirements of the 2012 Edition of the National Fire (12-21-LSC)

• Hospital and Critical Access Hospital (CAH) Facility Life Safety Code (LSC) Occupancy Classification (11-05-LSC)

• Interior Finish Documentation Requirements for Multiple Providers -Hospitals, Ambulatory Surgical Centers (11-07-LSC)

• 42CFR 483.470(i)(2)(i) Evacuation Drills for Mentally Retarded (ICFs/MR) Certified (10-26-LSC)

• Revision of SC-04-41, Corridor Width and Corridor Mounted Computer Touch Screens in Facilities (10-18-LSC)

• Waiver to Allow Hospitals to Use the NFPA 6-Year Damper Testing Interval (10-04-LSC)

• Life Safety Code (LSC) Surveyor Reference Materials (04-29)

• Life Safety Code (LSC) and State Performance Standards (04-33)

• Definitions of Terms Used in the LSC of the NFPA (04-15)

• For Surveyors and/or Facilities

• For Designers

• Affects physical environment


S&C 11-05-LSC

• Certification

(federal) vs.

Licensure (state)

requirements


S&C 11-05-LSC

• Many hospitals include noncontiguous or off-site facilities that provide outpatient services, such as ambulatory surgery, general and specialty physician services, physical therapy, urgent care and others. These ‘‘component facilities’’ (the term used in the Guidance) are encouraged for a number of reasons. They offer hospital-level services to patients in the community; they promote efficiencies in the healthcare system by integrating the delivery of care under the hospital; and they extend and solidify the hospital’s brand in an increasingly competitive health care marketplace.


S&C 11-05-LSC

• The Medicare provider-based rules require significant integration between a hospital and a component facility, as demonstrated by joint licensure (except in states where joint licensure is prohibited, in which case an exception may be granted), a shared medical staff, financial integration, and significant clinical and administrative oversight of the facility, among other conditions.

• In effect, the provider-based facility is like any another department or clinic of the hospital, except that it is not located within the hospital’s four walls.


S&C 11-05-LSC

• Health Care Occupancy (Hospital)– Provides sleeping accommodations

– Medical treatment/services on a 24-hour basis

– Patients mostly incapable of self-preservation

• Ambulatory Health Care Occupancy (Surgical Center 23-hrs or less)– Does NOT provide sleeping accommodations

– Does NOT provide medical treatment/services on a 24-hour basis

– Provides anesthesia services

– Patients mostly incapable of self-preservation

• Business Occupancy (Urgent Care)– Does NOT provide sleeping accommodations

– Does NOT provide medical treatment/services on a 24-hour basis

– Does NOT provide anesthesia services

– Patients mostly capable of self-preservation


S&C 11-05-LSC

“A patient may be incapable of self-preservation due to many factors, including, but not limited to, age, physical or mental disability, medical or therapeutic interventions, medication reactions, etc. ... In addition, when determining the ability for self preservation, consideration should be given to both the characteristics of current patients and the characteristics of patients the facility is likely to provide medical treatment or services to in the future, as evidenced by the provider’s own advertisement and clientele to which the provider holds itself out to serve.”


S&C 11-05-LSC

“Section 1861(e) of the Social Security Act (the Act) defines “hospital” as being primarily engaged in providing care to inpatients and is not based upon a minimum number patients receiving treatment, care or services. CMS does not consider the number of patients in determining if a provider is a hospital or a CAH; therefore, a CMS-certified hospital or CAH does not need to have four or more inpatients at all times in order to be classified as a Health Care Occupancy. Occupancy classification must be determined regardless of the number of patients served at a hospital’s or CAH’s component facility. ”


Questions to ask (HC) Clients


Questions to Ask our (HC) Clients

• Q1. Is <Insert Project Here> currently a licensed health care facility by the State Health Department?

• Q2. Is there a desire, currently or in the future, for <Insert Project Here> to house individuals / groups / practices that will bill healthcare services under your organization’s CMS provider number ?

• Affirmative response to either of these options will trigger the 2000 NFPA 101 Life Safety Code (LSC) as an additional required code for the project.


CMS Billing Clarification


Clinic facility fees

• Sec. 1861. [42 U.S.C. 1395x]

• Clinic facility fees (CFF) have become a hot button issue as more Medicare patients seek care in hospital-affiliated clinics, and as hospitals purchase medical offices and rebrand them as an arm of the hospital. That can result in patients seeing the same doctor in the same building, but suddenly being charged more because hospital facility fees are tacked on. – Paying twice as much for routine medical care because of CFF

• Physician’s office = Single payment

• Outpatient department or an ASC– Medicare pays twice: (1) To the facility and (1) to the provider

– WHY? Meant to cover hospital’s overhead that a freestanding physician’s office does not carry.


National Provider Identifier

• 45 CFR Part 162 [CMS–0045–F]

– HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers

• Unique health identifier for health care providers for use in the health care system

• Adoption of National Provider Identifier (NPI)

• Effective Date : May 23, 2005


Project Example


Example : MOB added to Hospital

• Provided only outpatient services

• Outpatients all capable of self-preservation

• Services billed to private physician’s CMS-provider number

• MOB separated from Hospital w/a 2Hr FB … connected w/a bridge

• MOB = Business

• MOB designed to comply with IBC only & not LSC or HC Licensure


Example : MOB added to Hospital

• Years later …– Hospital purchases MOB

– Wants to bill services to their CMS-provider number

– Assumed it was a simple “change” to their Hospital license

• Design Issues– 2-story vertical opening open to the

corridors

– Plenum mechanical returns


Design Issues

• 2-story vertical opening

open to the corridors

• Plenum mechanical returns



T H A N K Y O U F O R

AT T E N D I N G


how licensure affects the applicable codes for healthcare projects

Engineering