Hospitals and Critical Access Hospitals

The Centers of Medicare and Medicaid Services (CMS) pre-published a final rule (effective July 11, 2014) that would "Save hospitals significant resources by permitting registered dietitians and other qualified nutrition professionals to order patient diets independently, which they are trained to do, without requiring the supervision or approval of a physician or other practitioner. This frees up time for physicians and other practitioners to care for patients." According to CMS in the final rule, "[t]he addition of ordering privileges enhances the ability that RDNs already have to provide timely, cost-effective, and evidence-based nutrition services as the recognized nutrition experts on a hospital interdisciplinary team." This change only applies to RDNs privileged by the hospital in which they work.

As CMS previously noted, "Our intent in revising the provision was to provide the flexibility that hospitals need under federal law to maximize their medical staff opportunities for all practitioners, but within the regulatory boundaries of their State licensing and scope-of-practice laws. We believe that the greater flexibility for hospitals and medical staffs to enlist the services of non-physician practitioners to carry out the patient care duties for which they are trained and licensed will allow them to meet the needs of their patients most efficiently and effectively." Relevant portions of the final rule are on pages 5, 11, 13, 33, 43-52, 112, 144-145, 150-159, 177-178 and 186-187.

Under the rule, qualified dietitians or qualified nutrition professionals are explicitly permitted to become privileged by the hospital's medical staff to (a) order patient diets, (b) order lab tests to monitor the effectiveness of dietary plans and orders, and (c) make subsequent modifications to those diets based on the lab tests, if in accordance with state laws including scope of practice laws and specifically authorized by the medical staff. CMS made this change because it "believe[s] that RDs are the professionals who are best qualified to assess a patient's nutritional status and to design and implement a nutritional treatment plan in consultation with the patient's interdisciplinary care team." CMS did note that lab ordering "privileges for dietitians and nutrition professionals are not required or specifically allowed by this requirement, but are instead an option left to hospitals and their medical staffs to determine in consideration of relevant State law as well as any other requirements and/or incentives that CMS or other insurers might have." CMS's new rule is in accordance with longstanding federal law that has allowed qualified dietitians and qualified nutrition professionals the ability to work in hospitals to provide nutrition services. Under the new rule, hospitals have the authority to determine who will be privileged.

There is not presently a definition of therapeutic diet in the CMS Conditions of Participation regulating hospitals. CMS has acknowledged the Academy-approved "therapeutic diet" definition in interpretive guidance for the Resident Assessment Instrument Manual 3.0. The Academy will continue to work with CMS to encourage adoption of the definition for hospitals and across the continuum of care. In the Federal Register from May 12, 2014 announcing the hospital rule change, CMS stated they "consider all patient diets to be therapeutic in nature, regardless of the modality used to support the nutritional needs of the patient, and that the term would most certainly include enteral and parenteral nutrition support."

The CMS Conditions of Participation for hospitals do not clearly define the term "qualified dietitian," but the interpretive guidelines indicate that "Qualification is determined on the basis of education, experience, specialized training, State licensure or registration when applicable, and maintaining professional standards of practice." CMS defines "qualified dietitian" in other care settings that may be used for guidance in hospitals. In long term care facilities, a qualified dietitian is one who is qualified based upon either registration by the Commission on Dietetic Registration of the American Dietetic Association, or on the basis of education, training, or experience in identification of dietary needs, planning, and implementation of dietary programs. In transplant centers, "a qualified dietitian is an individual who meets practice requirements in the State in which he or she practices and is a registered dietitian with the Commission on Dietetic Registration." The final rule indicates it is CMS's "intention … to include all qualified dietitians and any other clinically qualified nutrition professionals, regardless of the modifying term (or lack thereof), as long as each qualified dietitian or clinically qualified nutrition professional meets the requirements of his or her respective State laws, regulations, or other appropriate professional standards."

Before an RDN will be legally permitted to order patient diets, the RDN must become part of the medical staff or be granted privileges by the hospital to order therapeutic diets. In addition, given the abundance of state laws and regulations that mirrored the restrictive regulation that CMS has revised, it is important to be aware of the progress state legislatures and regulatory authorities have made in ensuring consistency with this new rule. The Academy has provided an updated map of state regulatory status.

Privileging is the process by which a hospital's medical staff individually evaluates each practitioner and determines that he or she has the qualifications and demonstrated competence to perform all of the specific tasks for which privileges are granted.

Privileged RDNs should be able to order nutritional supplements for patients in accordance with state laws and regulations.

As defined in the Academy Definitions of Terms, credentialing to be a member of the medical staff is more general, and a prerequisite to privileging, in which a professional's specific scope of practice in a particular facility is defined.

Yes. The final rule specifically clarifies that RDNs may be included on the medical staff, as they "have equally important roles to play on a medical staff and on the quality of medical care provided to patients in the hospital."

In addition, the final rule reviewed suggestions that would enable RDNs and other practitioners to furnish and bill for site telehealth services through rural health clinics (RHC) in a way that will not result in duplicate payment (once through the Medicare RHC cost report and again through the Medicare Part B physician fee schedule payment).