Meet Stress Testing Supervision Requirements

Provider rules change depending on whether you’re reporting for inpatient or outpatient services.

By Jill M. Young, CPC, CEDC, CIMC
When reported to Medicare, cardiac (93015-93024) and pulmonary (94620-94621) stress tests must meet applicable supervision requirements. You also must remember that in the outpatient setting only a physician—never a non-physician practitioner (NPP)—may act as the supervising entity for diagnostic tests.

Know the Supervision Levels Required

Medicare specifies supervision requirements for all diagnostic services, as found in the “Physician Supervision of Diagnostic Procedures” column of the National Physician Fee Schedule Relative Value File. The file lists the following supervision requirement indicators for stress tests:

The supervision requirement indicators correspond to the following supervision levels:
1—Procedure must be performed under general supervision: The procedure is furnished under the physician’s overall direction and control. The physician must order the diagnostic test and is responsible for training the staff performing the tests, as well as maintaining the testing equipment. He or she does not need to be present in the room during the procedure.
2—Procedure must be performed under direct supervision: The physician needn’t be present in the room, 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.
In the physician office, and for hospital outpatient diagnostic services provided under arrangement in nonhospital locations (such as independent diagnostic testing facilities and physicians’ offices), the supervising physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure.
For services furnished directly or under arrangement in the hospital or an on-campus provider-based department (PBD), the supervising physician must be present on the same campus and immediately available to furnish assistance and direction throughout the performance of the procedure. That is, the Centers for Medicare & Medicaid Services (CMS) permits direct supervision from locations that are not in the hospital space, but that are “close,” as long as the physician is immediately available.
3—Procedure must be performed under personal supervision: A physician must be in the room during the performance of the procedure.
9—Concept does not apply: A physician must perform the service personally. This usually denotes the professional component of a service, or a global service that includes/bundles the professional component.
Tip: You may download the Physician Fee Schedule Relative Value File from the CMS website. Select the most recent (last-listed file) for download.
As an example, a full cardio stress test (93015) must be performed under direct supervision (at a minimum), while the technical component of an ergonovine provocation (93024-TC) must be performed under the personal supervision of the physician. To report the global ergonovine provocation test (93024), the physician personally must perform the service.

Use Caution When Involving NPPs

“Physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives who do not meet the definition of ‘physician’ may not function as supervisory physicians for the purposes of diagnostic tests,” according to the 2010 Hospital Outpatient Prospective Payment System (OPPS) Final Rule (Federal Register, Nov. 20, 2009). Many times we see our NPPs and physicians listed together as a provider type, but when it comes to supervision for these tests, this cannot be the case. Only “a doctor of medicine or osteopathy legally authorized to practice medicine in his or her state of practice,” may act as a supervisory physician for diagnostic services in an outpatient setting (hospital outpatient or physician office). And, the supervising physician must have the “knowledge, skills, ability and privileges to perform the service or procedure”—so not just any doctor will do.
Note that Medicare physician supervision requirements do not apply to hospital inpatient services. For inpatient services, CMS defers to hospital policy and Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards.
Medicare specifies that NPPs (such as physician assistants (PAs), nurse practitioners (NPs), certified nurse specialists, certified nurse midwife) may order, perform, and bill for diagnostic tests as specifically granted under their state Scope of License, but Public Health Code and other regulations in place still require overarching physician collaboration, or a level of supervision by physicians, in the performance of these tests. To quote the Medicare Benefits Policy Manual, chapter 6, section 20.4.5:
“exceptions … allow some diagnostic tests furnished by certain non-physician practitioners to be furnished without physician supervision. While these nonphysician practitioners including physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives cannot provide the required physician supervision when other hospital staff are performing diagnostic tests, when these nonphysician practitioners personally perform a diagnostic service they must meet only the physician supervision requirements that are prescribed under the Medicare coverage rules at 42 CFR Part 410 for that type of practitioner when they directly provide a service. For example, under 410.75 nurse practitioners must work in collaboration with a physician, and under 410.74 physician assistants must practice under the general supervision of a physician.”
The compliance implications of these requirements need to be considered in your practice, particularly if you are performing stress tests. At a minimum, for diagnostic tests in the outpatient setting:

• Be sure that the physician documents specifically the level of supervision provided. CMS guidelines specify, “Documentation maintained by the billing provider must be able to demonstrate that the required physician supervision is furnished.”
• NPPs never may act as a supervising physician.

An NPP looking to order or perform a specific test first should check at a state level to determine if he or she is qualified to do so. If a mid-level provider administers the test without physician supervision, the medical record should document clearly that the service is within the provider’s scope of practice as allowed by state law, and the procedure billed under the name of the NPP.

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