Starting July 11, 2014, Registered Dietitian Nutritionists will be able to order diets in hospitals under Centers for Medicare and Medicaid Services (CMS) regulation. According to CMS, “the 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.”
While this is a big win for dietitians, it is important to understand that the new CMS rule allows dietitians to write orders, but it is not a requirement for hospitals.
What you need to know about the new regulation:
- CMS revised the proposed regulatory language from the draft. In this final rule CMS requires that all patient diets, ‘‘including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals.’’
- This regulation does not require hospitals and medical staff to grant or authorize specific privileges to specific practitioners, but only allows them the flexibility to do so if they choose, and only if State law allows for it.
- “Qualified dietitian” and “qualified nutrition professional” is the termed used by CMS in this regulation. This means an RD, RDN and “qualified” nutrition professional “…is 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.”
- RDN’s can be included as part of the medical staff. This is not a requirement, but something a hospital can do, as long as it is in the scope of practice and allowed by the state they practice in.
- If a state does not allow an RDN to become part of the medical staff, the hospital and medical staff can grant specific practice privileges to specific categories of practitioners. This means that RDNs can be granted order writing privileges by the medical staff without them being a part of the medical staff.
- CMS considers all diets in the hospital to be therapeutic, including enteral and parenteral nutrition. This would allow RDNs to write orders for tube feedings and TPN.
There was some talk about allowing RDNs to write orders for lab tests. Here is what was in the CMS regulation:
As proposed, and as finalized here, the regulatory language did not include privileges for ordering lab or other diagnostic services by dietitians or nutrition professionals. However, the preamble to this section of the proposed rule did include a discussion of such privileges in the context of some of the research cited. Such 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.
It seems that the issue of ordering lab test is a bit more complex, as there are rules and regulations that vary by state and also insurance company. It appears that CMS has opened the door to the possibility of RDNs writing orders for labs, but it will be more difficult for RDNs to be able to do this.
The Academy of Nutrition and Dietetics has more information on their website, including “Frequently Asked Questions.”
For the complete CMS regulation, visit: https://www.federalregister.gov/articles/2014/05/12/2014-10687/medicare-and-medicaid-programs-regulatory-provisions-to-promote-program-efficiency-transparency-and