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CMS Provides Clarification on Supervision Requirements for CSWD in Hospital Outpatient Setting

Tuesday, March 31, 2015   (2 Comments)
Posted by: Becky Dryden
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The Centers for Medicare & Medicaid Services (CMS) announced in March 2014 that it would require a Direct Supervision requirement for anyone performing CPT code 97597 Debridement in the hospital outpatient setting. CPT code 97597 is defined as: (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20sq cm or less. CMS argued that 97597 was not within the scope of practice for a nurse and was not safe for General Supervision requirements.

Throughout the last year, the WOCN Society has been working with CMS to provide more detail about how this decision was made and what the "Direct Supervision" requirements mean when applied to the clinical setting.In March of 2015, the Society testified before CMS's Advisory Panel on Hospital Outpatient Payment (the Panel) regarding the supervision requirements for CSWD. The Panel is charged with advising CMS on the appropriate supervision levels for individual hospital outpatient therapeutic services, including CSWD. The Society argued that 97597 is clearly within the scope of a certified WOC nurse and can be safely performed by a qualified nurse.

During the course of the exchange with members of the Panel and CMS staff, it became clear that the Panel did feel comfortable with a certified-WOC nurse being able to perform this procedure safely and under General Supervision requirements. However, CMS does not have the authority to exempt certain certified providers from supervision requirements and thus must apply the supervision requirements to anyone who might be performing the procedure. CMS will not alter the supervision requirements for 97597 and they will continue to require Direct Supervision for anyone performing the procedure.

What do the "Direct Supervision" requirements mean for you in the clinical setting?

If a procedure, such as 97597, falls under the Direct Supervision requirement, it means that "the physician or non-physician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician or non-physician practitioner must be present in the room when the procedure is performed." These supervision requirements are defined under the Code of Federal Regulations at 42 CFR 410.27, and members are encouraged to visit this site as a reference. It is worth repeating that Direct Supervision does not mean that a physician be present in the room during the procedure. It simply means that a physician or appropriate non-physician practitioner (NPP) is immediately available to furnish assistance and direction throughout the performance of the service. "Immediately available" does not have a specific time or distance requirement, and means physically present to intervene without passage of significant time. Generally it means the supervisor must be on site or very close by.

If your institution is interpreting this supervision requirement differently than what is reported here, please direct them to the aforementioned reference. If you have further questions please contact the Society's Director of Government Relations, Chris Rorick, at


Becky Carroll says...
Posted Monday, April 13, 2015
Hi Patricia, I have been advised that it has no impact on the home health setting. Thanks, Becky Dryden, WOCN Website and Publications Editor
Patricia A. Cable says...
Posted Saturday, April 11, 2015
As a CWCN in a home care agency I find this very distressing. There is no separate billing for my services. Wound care procedures including enzymatic and conservative sharp debridement, dressing products, etc are provider order driven. But those orders are commonly based on my assessment and recommendations. It goes without saying that in the home health care setting there no physicians on site while wound care is being provided. I was also concerned that included in the exclusions list of actions that are to be accomplished only with direct supervision was assessment. Please comment on how this direct supervision requirement is intended to affect the home health care setting.

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