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July/August 2016
Virtual Supervision of “Incident To” Services
IDSA Outlines Implications for OPAT 
The American Medical Association (AMA) circulated a resolution at its Annual House of Delegates Meeting in June regarding “incident to” services—defined as services or supplies furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness. The AMA’s resolution “supports pilot programs in the Medicare program to enable virtual supervision of ‘incident to’ services that require direct supervision if those programs abide by certain principles.” 
AMA’s resolution may have implications to IDSA members in clinical practice, including those who provide outpatient parenteral antibiotic therapy (OPAT), which IDSA believes requires some supervision by an ID physician. AMA’s resolution states:
  • The physician billing the “incident to” services must meet requirements of direct supervision of “incident to” services, which includes seeing the patient and initiating the course of treatment, and providing services that shows active management and participation in the course of treatment.
  • Supervision by the physician should conform to all applicable state laws.
  • Non-physician practitioners must follow all state licensing laws and state medical practice laws during the provision of the “incident to” services.
  • State scope of practice laws must be followed and the physician must be connected through real-time audio and video technology with the room where the service is provided, and to ensure that the physician is immediately able to provide assistance. 
  • Virtual supervision of “incident to” services must follow evidence-based practice guidelines when available.
  • The physician providing the virtual supervision should visit the sites where the “incident to” services will be performed.
  • Physicians providing virtual supervision of the “incident to” services must establish protocols for arranging emergency services “including having an agreement with a physician at the site at which the ‘indecent to’ services are provided, to ensure immediate assistance.” 

IDSA has developed a position statement (PDF) that says virtual supervision of services such as OPAT should only be allowed if there is a practitioner on site to provide immediate assistance in case of adverse events such as an allergic reaction during an IV infusion. For infusions covered under the “incident to” rules, IDSA states that the first infusion should be provided to the patient during a face-to-face encounter with the supervising physician, but that it may be possible, for subsequent infusions to be supervised virtually.

IDSA’s position is that virtual supervision cannot provide “hands on” assistance that is needed for services such as IV infusions. Furthermore, in cases of infusion of OPAT, IDSA believes it is important for an ID physician to provide input and consultation on the use of OPAT, but that the ID physician does not have to be physically present as long as another physician is physically onsite to provide immediate assistance, if needed, during the initial OPAT treatment. 

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