How Much Direct Supervision Does 95165 Require?

Look to incident-to rules for clarity.

By G.J. Verhovshek, MA, CPC
Question: I am trying to determine what level of physician supervision is required for “supervision of preparation and provision of antigens for allergen immunotherapy” (95165). The Medicare Physician Fee Schedule assigns a “Physician Supervision” requirement of 9, or “concept does not apply.” How do I interpret this? Does the physician have to be in the office during allergy serum preparation?
Answer: Antigen preparation, as described by 95165 Professional services for the supervision of preparation and provision of antigens for the allergen immunotherapy; single or multiple antigens (specify number of doses) is a therapeutic service, so requirements for physician supervision of diagnostic procedures—as described by Medicare’s Physician Fee Schedule (MPFS)—do not apply. For Medicare patients in the physician office, services performed by a qualified non-physician practitioner (NPP) must meet incident-to guidelines.
For a service to qualify as incident-to:

  • The NPP must be licensed or certified to provide professional health care services in the state where the physician practice is located.
  • Generally, the NPP must be a full-time, part-time, or leased employee of the physician or physician group practice. (In limited cases, the NPP may be an independent contractor of the physician or physician group practice.)
  • The NPP must provide services as an integral part of and incident-to the physician’s services.
  • The NPP must provide such services under the direct supervision of the physician.

Per Medicare rules, direct supervision means the supervising physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. The physician does not need to be present in the room during the procedure, but must not be performing another procedure that cannot be interrupted, and must not be so far away that he or she could not provide timely assistance. Documentation should substantiate that the physician was present, on site, to supervise the mixing of the antigens.
Incident-to rules do not apply to a hospital setting. Per 2011 Hospital Outpatient Prospective Payment System (OPPS) Final Rule, therapeutic services in an outpatient setting may be provided:

  • Under the direct supervision of an MD or DO, or
  • Under the direct supervision of a physician assistant, nurse practitioner, clinical nurse specialist, certified nurse-midwife, licensed clinical social worker, or clinical psychologist who could personally furnish the service “in accordance with State law.” The supervising NPP must be privileged by the hospital to perform the services he or she supervises, and must abide by any applicable hospital physician-collaboration or supervision requirements.

Note: Medicare physician supervision requirements do not apply to hospital inpatient services. For inpatient services, the Centers for Medicare & Medicaid Services (CMS) defers to hospital policy and Joint Commission (formerly JCAHO) standards.

G.J. Verhovshek, MA, CPC, is managing editor at AAPC.
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