CPCS Clinical Privileging 2 — Questions and Answers
Question 1: Which document serves as the primary basis for delineating a provider's clinical privileges at a hospital?
- The provider's curriculum vitae
- The medical staff bylaws (Correct answer)
- The Joint Commission standards manual
- The provider's malpractice history report
Correct answer: The medical staff bylaws
Medical staff bylaws define the framework, criteria, and processes by which clinical privileges are granted, modified, or denied.
Question 2: A physician applies for laparoscopic cholecystectomy privileges but has only performed open cholecystectomies. What is the MOST appropriate next step?
- Deny the request outright
- Grant full privileges with a one-year probationary period
- Require proctoring or supervision for a defined number of cases (Correct answer)
- Refer the matter to the state medical board
Correct answer: Require proctoring or supervision for a defined number of cases
When a provider lacks demonstrated competency in a specific procedure, requiring supervised proctoring ensures patient safety before granting independent privileges.
Question 3: Under FPPE, how long is a focused evaluation period typically conducted for a newly privileged provider?
- Until the first adverse event
- For a minimum of six months or a defined case volume (Correct answer)
- Until the next reappointment cycle
- Only during the first 30 days of practice
Correct answer: For a minimum of six months or a defined case volume
FPPE for new providers typically runs for an initial period—commonly six months or a set number of cases—before transitioning to OPPE.
Question 4: Which of the following best describes 'telemedicine privileges' in the context of clinical privileging?
- Privileges automatically granted by the distant site based on licensure
- Privileges granted by the originating site mirroring those of the distant site hospital (Correct answer)
- Privileges that require separate full credentialing at every site of service
- Privileges exclusively governed by CMS Medicare conditions of participation
Correct answer: Privileges granted by the originating site mirroring those of the distant site hospital
CMS and accreditation standards allow an originating site to grant telemedicine privileges based on the credentialing and privileging performed by the distant site, provided an agreement exists.
Question 5: A department chair recommends denial of privileges for a cardiologist based solely on competitive business concerns. What principle does this violate?
- HIPAA privacy regulations
- The Health Care Quality Improvement Act's fair hearing requirements
- Economic credentialing prohibitions under state law and accreditation standards (Correct answer)
- The Americans with Disabilities Act
Correct answer: Economic credentialing prohibitions under state law and accreditation standards
Using economic or competitive factors rather than competency and patient safety as the basis for privileging decisions constitutes improper economic credentialing.
Question 6: What is the purpose of a 'privilege card' or 'delineation of privileges' form?
- To document a provider's malpractice insurance limits
- To list the specific procedures and clinical activities a provider is authorized to perform (Correct answer)
- To verify a provider's board certification status
- To record a provider's peer references
Correct answer: To list the specific procedures and clinical activities a provider is authorized to perform
A privilege card or delineation of privileges form specifies exactly which procedures and clinical activities the medical staff has authorized a provider to perform at the facility.
Question 7: When a provider's clinical privileges are voluntarily relinquished while under investigation, what reporting obligation typically applies?
- No reporting is required if the provider resigns before a formal hearing
- The resignation must be reported to the National Practitioner Data Bank (Correct answer)
- The state licensing board must be notified within 24 hours
- The provider must notify all hospitals where they hold privileges
Correct answer: The resignation must be reported to the National Practitioner Data Bank
Under HCQIA, voluntary relinquishment of privileges while under investigation or in return for not conducting an investigation must be reported to the NPDB.
CPCS Clinical Privileging 2
Which document serves as the primary basis for delineating a provider's clinical privileges at a hospital?