Let Me Be Direct About Physician Supervision Requirements

Besides having patients’ lives in their hands, clinicians must observe loads of rules and requirements.

When it comes to directing the care of services performed by clinical staff (e.g., qualified healthcare professionals, ancillary staff, technicians, residents, fellows), it’s important to understand the levels of physician or non-physician practitioner (NPP) supervision required to satisfy billing and regulatory requirements.
You have to feel somewhat sorry for physicians, particularly those who work in large healthcare delivery systems where innumerable professionals participate in patient care. Some locations in which physicians practice are provider-based settings (i.e., facility), while others are physician-based, and the patient’s payer class isn’t necessarily broadcast with a flashing light. If you do not understand why it’s so difficult for physicians to grasp the supervision rules governing billing services, try walking a mile in their paper-booty covered shoes.
To understand the required level of physician supervision for billing, physicians must know whose definition applies, who is being supervised, what is being supervised, and where the service is being supervised. There are varying degrees of physician supervision dictated by Medicare Parts A, B, and C, as well as state Medicaid fiscal intermediaries (whose definition may be regulated by state law), state regulations governing licensing of certain professions (e.g., Board of Medicine or Board of Nursing), and even the Accreditation Council for Graduate Medical Education (ACGME). Throw in some private payers who may have their own requirements for physician supervision, and perhaps you’ll start to understand why physicians don’t always get this stuff right.
Medicare Professional Billing of Diagnostic Services
With limited exceptions, diagnostic X-rays and other diagnostic tests covered under the Medicare Physician Fee Schedule (MPFS) must be provided under some level of physician supervision, or the services will not be considered reasonable and necessary. The level of physician supervision for diagnostic tests varies based on the complexity of the service. For most of these services, three levels of physician supervision are applicable: general, direct, and personal (42 CFR 410.32).
General supervision means the service is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the non-physician personnel who actually perform the diagnostic procedure and maintain the necessary equipment and supplies, is the physician’s continuing responsibility.
Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the service; however, the physician does not need to be in the room when the service is performed.
Direct supervision is defined from the perspective of the office setting; therefore, you must determine whether the service in question is provided in an office setting (non-facility) or a facility setting. Direct supervision in an outpatient hospital setting is defined differently.
Personal supervision means a physician must be in attendance in the room during the performance of the procedure.
Medicare regulations also state that diagnostic X-rays and other diagnostic tests must be furnished under the appropriate level of supervision by a physician, and may not be supervised by NPPs; however, certain exceptions are afforded for some diagnostic tests furnished by some NPPs. In a nutshell, this means physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists, and certified nurse midwives may not supervise other staff in the performance of a diagnostic test; but when these same NPPs perform the tests themselves, the only level of physician supervision needed is that which is required for all services performed by that specific NPP. For example, NPs must work in collaboration with a physician, and PAs must practice under the general supervision of a physician.
Medicare Part B Incident-to Billing
Coverage of services and supplies incident-to the professional services of a physician are limited to situations in which there is direct physician supervision of auxiliary personnel. Again, direct supervision in the office setting does not mean the physician must be in the same room with his or her aide; however, the physician must be in the office suite and immediately available to provide assistance and direction throughout the time the aide performs services. This concept also applies to NPPs who are supervising auxiliary personnel. The definition of “direct supervision” for incident-to billing mirrors that of professional billing for diagnostic services.
Outpatient Facility Billing
Under the Outpatient Prospective Payment System (OPPS), the level of supervision, who may supervise, and the proximity of the supervising party to the location where the service is performed varies, based on whether the service is diagnostic, therapeutic, or falls under the category of nonsurgical extended duration therapeutic services (NSEDTS).
Diagnostic Services
For diagnostic services furnished in an on-campus or off-campus outpatient department of the hospital, “direct supervision” means the supervisory practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure. The supervisory practitioner is not required to be present in the room where the procedure is being performed, or within any other physical boundary, as long as he or she is immediately available. The supervisory practitioner may be present in locations, such as physician offices that are close to the hospital, or the provider-based department of a hospital where the services are furnished but are not located in actual hospital space, as long as the supervisory physician remains immediately available.
Immediate availability requires immediate physical presence of the supervisory physician. The Centers for Medicare & Medicaid Services (CMS) has not specifically defined the word “immediate” in terms of time or distance; however, an example of lacking immediate availability would be situations where the supervisory physician is performing another procedure or service that he or she could not interrupt. Also, for services furnished on-campus, the supervisory physician may not be so physically distant from the location where hospital outpatient services are furnished that he or she could not intervene right away. The hospital or supervisory physician must judge the supervisory physician’s relative location to ensure he or she is immediately available.
Therapeutic Services 
Physicians, clinical psychologists, licensed clinical social workers, PAs, NPs, clinical nurse specialists, and certified nurse midwives may furnish the required supervision of hospital outpatient therapeutic services in accordance with state law and all additional rules governing the provision of their services. Medicare requires direct supervision of all hospital outpatient therapeutic services unless CMS makes an assignment of either general or personal supervision for an individual service. For these services, direct supervision means the immediate availability to furnish assistance and direction throughout the performance of the procedure. General and personal supervision were already defined under “Professional Billing of Diagnostic Services.” For pulmonary rehabilitation, cardiac rehabilitation, and intensive cardiac rehabilitation services, direct supervision must be furnished by a doctor of medicine or a doctor of osteopathy.
NSEDTS
There is a hybrid level of supervision for certain services described as NSEDTS, which are hospital or critical access hospital outpatient therapeutic services that:

• Can last a significant time;
• Have a substantial monitoring component typically performed by auxiliary personnel;
• Have a low risk of requiring the supervisory practitioner’s immediate availability to furnish assistance and direction after the initiation of the service; and
• Are not primarily surgical in nature.

In the provision of these services, CMS requires a minimum of direct supervision during the initiation of the service, which may be followed by general supervision for the remainder of the service at the discretion of the supervisory practitioner. Initiation is the beginning portion of the NSEDTS that ends when the patient is stable and the supervising physician or appropriate NPP determines the remainder of the service can be delivered safely under general supervision. 
For these services, direct supervision is the immediate availability to furnish assistance and direction throughout the performance of the procedure. General supervision means the service is performed under the supervisory practitioner’s overall direction and control, but his or her presence is not required during the performance of the procedure.
The list of services that may be furnished under general supervision or that are defined as non-surgical extended duration therapeutic services is available on the CMS website.
ACGME
The ACGME Program Requirements for Graduate Medical Education in General Surgery states that the residency program must use the following classifications of supervision to ensure oversight of resident supervision and graded authority and responsibility:
Direct Supervision – the supervising physician is physically present with the resident and patient.
Indirect Supervision –

with direct supervision immediately available – the supervising physician is physically within the hospital or other site of patient care, and is immediately available to provide direct supervision.

with direct supervision available – the supervising physician is not physically present within the hospital or other site of patient care, but is immediately available by means of telephonic and/or electronic modalities, and is available to provide direct supervision.

Oversight – the supervising physician is available to provide review of procedures/encounters with feedback provided after care is delivered.
As you can see, the definition of direct supervision as it applies to the supervision of diagnostic tests billed under the MPFS differs greatly from ACGME’s definition, which is more in line with Medicare’s definition of personal supervision. ACGME also includes terms that Medicare does not recognize. In part, the ACGME definition for indirect supervision (i.e., with direct supervision immediately available) looks very similar to Medicare’s definition for direct supervision — at least as far as the physician office is considered.
Residents and fellows are afforded progressive responsibility commensurate to their level of training. The level of teaching physician supervision is based on the resident or fellow’s competence and experience, as well as ACGME residency program guidelines.
The level of teaching physician supervision and participation (and documentation) needed to support compliant billing may be more stringent than the levels described in ACGME residency program protocols, regardless of the resident or fellow’s experience or demonstrated competence.
State Medicaid Programs
Each state’s Medicaid program may establish the level of physician supervision required for certain services. For example, in the Florida Medicaid Practitioner Services Coverage and Limitations Handbook, personal supervision is required to bill services performed by a PA or advanced registered nurse practitioner under the physician’s provider number. The Florida Administrative Code, 59G-1.010 (276) defines direct supervision as “face-to-face supervision during the time the services are being furnished,” while personal supervision is defined as services furnished “while the supervising practitioner is in the building ….” As such, Florida’s definition of personal supervision is more in line with Medicare’s definition of direct supervision.
Staying on top of these various levels of supervision may not be rocket science, but cut your physicians some slack. In addition to keeping up with all of these billing and regulatory requirements, they have another very important job to perform: Taking care of patients.

 
Maryann C. Palmeter, CPC, CENTC, is employed with the University of Florida Jacksonville Healthcare, Inc., as the director of physician billing compliance where she provides professional direction and oversight to the billing compliance program of the University of Florida College of Medicine – Jacksonville. Her extensive experience in federal and state government payer billing and compliance regulations has been gained through working on both the physician billing and government contractor sides of the healthcare industry. Palmeter served on the National Advisory Board from 2011-2013 and served as secretary from 2013-2015. She was named AAPC’s 2010 “Member of the Year” and is a member of the Jacksonville, Fla., local chapter.

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Maryann Palmeter

Maryann C. Palmeter, CPC, CPCO, CPMA, CENTC, CHC, has more than 30 years of technical and executive level experience gained through her work on both the government payer and professional billing ends of the healthcare spectrum. She is director of physician billing compliance at the University of Florida Jacksonville Physicians, Inc., and is responsible for providing professional direction and oversight to the billing compliance program of the University of Florida College of MedicineJacksonville. Palmeter served on the AAPC’s National Advisory Board from 2011-2013 and was subsequently selected to serve as secretary for the 2013-2015 term. She was named the AAPC’s 2010 “Member of the Year” and is the vice president for the Jacksonville, Fla., local chapter.

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