What Are the Supervision Requirements for My Facility?

Ask your legal questions.

The non-physician practitioners (NPPs) at my specialized health system are documenting the name of the physician who supervised them on a particular day. Sometimes the supervising physician will leave our facility without co-signing the charts. Here are my questions about this.

Question: Is it appropriate for any physician in my clinic on the day of an NPP’s service to be the supervising physician?

Answer: The Centers for Medicare & Medicaid Services (CMS) Medicare Claims Processing Manual, Publication 100-02, chapter 15, section 60.2, clearly states that any physician within the clinic may provide direct supervision:

“In highly organized clinics, particularly those that are departmentalized, direct physician supervision may be the responsibility of several physicians as opposed to an individual attending physician. In this situation, medical management of all services provided in the clinic is assured. The physician ordering a particular service need not be the physician who is supervising the service.”

Question: What, if anything, needs to be documented in the electronic health record (EHR) to support another physician supervising the services when the original documentation indicates the absent physician was in supervision?

Answer: It sounds like the EHR is set up automatically to add the physician that initiated the plan when the NPP documents services as incident-to. If this is so, make sure that this physician’s information is populating Box 17 on the 1500 or its equal on the electronic claim as the ordering physician, and that the supervising physician is listed in Box 24J as the rendering physician on the 1500 or its electronic equal. We also recommend changing the EHR process so that the supervising physician’s name is not auto-populated into the EHR.

Per Medicare Claims Processing Manual, Publication 100-04, chapter 26, section 10.4:

“Item 24J – Enter the rendering provider’s NPI number in the lower unshaded portion. In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the lower unshaded portion.”

Question: If it’s appropriate to use a substitute physician, can the physician sign for all other types of auxiliary personnel services (i.e., medical assistant (MA), registered nurse (RN), registered respiratory therapist (RRT), audiologist, physical therapist (PT))?

Answer: Based on the information provided, the quick answer is “yes.” You also should consider, however, the type of service the auxiliary personnel is providing because not all services require that incident-to rules are met. These include auxiliary services such as venipuncture, electrocardiograms (EKGs), immunizations, etc. Check the benefit category each service falls into before applying incident-to rules.


Robert A. Pelaia, Esq., CPC, CPCO, is senior university counsel for health affairs at the University of Florida College of Medicine in Jacksonville, Fla. Pelaia is certified as a Health Care Law Specialist by the Florida Bar Board of Legal Specialization and Education.

Cynthia Stewart, CPC, CPC-H, CPMA, CPC-I, CCS-P, is the president of AAPC’s National Advisory Board (NAB). She has over 25 years of experience in the medical profession. She is a revenue cycle systems manager of coding and charge entry with St. Vincent Health in Indianapolis.


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One Response to “What Are the Supervision Requirements for My Facility?”

  1. Aman says:

    I would like to comment on the temniration of the Supervisory Agreement and the Collaborating Agreement. To terminate the Supervisory Agreement, a signature of the PA and physician are required and only the CRNP’s signature is required to terminate a Collaborating Agreement. A physician cannot terminate either of these agreements on his/her own.

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