Nutrition 411: New CMS Rule Gives Dietitians Order Writing Privileges

  The Centers for Medicare and Medicaid Services (CMS) announced a final rule that will allow registered dietitians (RDs) to become privileged to independently write orders beginning July 11, 2014.   The previous system allowed RDs only to make recommendations for nutritional interventions. This meant the RD had to communicate all recommendations to a nurse or unit clerk who, in turn, contacted the physician or licensed practitioner to obtain an order. Often, there were delays in getting the nutrition orders started in a timely fashion or the recommendations fell through the cracks entirely.

  With healthcare moving at warp speed toward finding ways to improve quality while seeking ways to lower costs by increasing efficiencies, this new rule is a natural fit. This final rule responds directly to the President’s instructions in Executive Order 13563 urging federal agencies to reduce or revise outmoded or unnecessarily burdensome rules and regulations. Many of the rule’s provisions streamline the standards healthcare providers must meet in order to participate in the Medicare and Medicaid programs without jeopardizing beneficiary safety. According to the CMS, “In order for patients to receive timely nutritional care, the RD must be viewed as an integral member of the hospital interdisciplinary care team, one who, as the team’s clinical nutrition expert, is responsible for a patient’s nutritional diagnosis and treatment in light of the patient’s medical diagnosis.”¹ Under the new rule, qualified RDs will be able to order patient diets and hospitals will be able to privilege them to order nutrition-related laboratory tests to monitor and modify diet plans without the supervision or approval of a physician. “Eliminating extra steps in the treatment process will free up resources, allowing all healthcare providers to care for patients more effectively and efficiently,” according to Glenna McCollum, Past President of the Academy of Nutrition and Dietetics. The CMS estimates the savings from the new rule at $459 million per year.

  Timely nutrition intervention is a critical part of the care plan for all patients with acute or chronic wounds. This new rule will help patients with wounds receive appropriate diet, vitamins and minerals, and oral nutrition supplements without any delay. It is important to discuss the implementation of this new rule with your medical executive committee so any bylaws and policies can be changed in accordance with the rule.

What Does This Final Rule Do?

  The CMS pre-published a final rule on May 7, 2014, finalizing a proposed rule change that would, among other things, “… save hospitals significant resources by permitting registered dietitians 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.”2 According to the CMS in the final rule, “[t]he addition of ordering privileges enhances the ability that RDs already have to provide timely, cost-effective, and evidence-based nutrition services as the recognized nutrition experts on a hospital interdisciplinary team.”2 It is important to note this change only applies to RDs privileged by the hospital in which they work and that the rule became effective July 11, 2014.

  As the 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. The entire rule can be read at www.federalregister.gov/articles/2014/05/12/2014-10687/medicare-and-medicaid-programs-regulatory-provisions-to-promote-program-efficiency-transparency-and.

Who Will be Able to Order Therapeutic Diets?

  Under the rule, qualified dietitians or qualified nutrition professionals will be explicitly permitted to become privileged by the hospital staff to 1) order patient diets, 2) order lab tests to monitor the effectiveness of dietary plans and orders, and 3) make subsequent modifications to those diets based on the lab tests, if in accordance with state laws including scope of practice laws. The 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.”² The 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.”²

  The CMS’ new rule is in accordance with long-standing 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 will have the authority to determine who will be privileged.

What is a “Qualified Dietitian or Qualified Nutrition Professional”?

  The Conditions of Participation for hospitals do not unambiguously 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.” The CMS defines “qualified dietitian” variously 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”) and 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 the CMS’ “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.”

What Else Does the Rule Specify?

  The final rule specifically clarifies that RDs 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 RDs and other practitioners to furnish and bill for site telehealth services through rural health clinics 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).

How is “Therapeutic Diet” Defined?

  Presently, therapeutic diet is not defined in the Conditions of Participation regulating hospitals. The CMS previously adopted the Academy-approved “therapeutic diet” definition and interpretive guidance for the Resident Assessment Instrument Manual 3.0. The Academy of Nutrition and Dietetics will continue to work with the CMS to encourage adoption of the definition for hospitals and across the continuum of care.

Practice Points

  Evidence is growing for the role of nutrition in reducing readmission rates, reducing the occurrence of never events (which includes inhouse-acquired Stage III and Stage IV pressure ulcers), and reducing hospital-acquired infections. All of these issues have serious financial implications for the facility as well as serious quality-of-life implications for the patient. With this rule change, the CMS has recognized the role of nutrition in creating better outcomes as well as the potential savings by improving nutrition care delivery systems. This rule change empowers RDs to be more valued members of the healthcare team. If your patient has nonhealing wounds, please consult your facility or local RD.

Nancy Collins, PhD, RD, LD/N, FAPWCA, FAND is founder and executive director of Nutrition411.com and Wounds411.com. For the past 20 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Correspondence may be addressed to Dr. Collins at NCtheRD@aol.com. This article was not subject to the Ostomy Wound Management peer-review process.

1. Academy Praises New Rule That Will Provide Hospital Patients With Better, Faster Nutrition Care Available at: www.todaysdietitian.com/news/052314_news.shtml. Accessed September 4, 2014.

2. FAQs — CMS Final Rule Related to Therapeutic Diet Orders. Available at: www.eatright.org/HealthProfessionals/content.aspx?id=6442474904. Accessed September 4, 2014.