Cardiology Coding Alert

Don’t assume Medicare rules are the only ones that apply.

Non-physician practitioners (NPPs) and ancillary staff are key to maximizing patient flow and physician time in cardiology practices. Not understanding and applying the supervision requirements, however, could actually cost your practice money in denials and lost reimbursement. 

If your physician assistant (PA) or nurse practitioner (NP) performs a diagnostic service, you know it’s important to meet supervision requirements. But keeping track of which supervisory levels Medicare requires for specific services can be daunting. Read on to learn the basics and set your practice on the right course for proper reimbursement and compliance. 

Important: Don’t confuse the supervision rules for diagnostic tests with the rules for billing “incident to” services. While the levels are similar, the application is different. 

Differentiate Requirement Levels

In most cases, if your physician does not directly provide all services a patient receives, you must nevertheless document a minimum level of physician supervision. The extent to which the physician must supervise ancillary staff varies by procedure.

CMS has designated three principle levels of physician supervision: general, direct, and personal:

Level 1, general: For procedures that require general supervision, “the procedure is furnished under the physician’s overall direction and control,” says Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac Medical Practice Consulting in Clearwater, Fla. “But the physician’s presence is not required during the procedure. The physician must order the diagnostic test but does not have to be in the office at the time of the performance of the test.” The physician is responsible for training the people who do the tests, as well as for maintaining the testing equipment.

Examples of procedures your staff might perform that only require general supervision are venipuncture (36415), dip stick urinalysis (81002), and the technical component of echocardiograms (for example, 93306-TC).

Level 2, direct: With direct supervision, the physician must be present in the office suite and immediately available to furnish assistance and direction. But the physician does not have to be in the room where the patient undergoes the test. Many consultants refer to this as “hollering distance.”

Examples of procedures your NPPs might perform that only require direct supervision include cardiovascular stress tests (93015-93017).

Level 3, personal: For these procedures, the physician must be in attendance in the testing room during the procedure. For a level-three service, the physician “must be physically in the room with the patient and the NPP providing the service. He or she cannot be across the hall with another patient or making phone calls at the front desk,” Mac stresses.

Examples of procedures that require personal supervision include chest X-ray with fluoroscopy (71023, specifically the technical component).

Tip: CMS also designated supervision levels 4, 5, and 6 to be specific to the practices of psychology, audiology and physical therapy, respectively. 

Pay Attention to State Regulations

While CMS assigns a required level of supervision for procedures and services as noted above, you have to look beyond Medicare’s policy. You also need to be aware of your state’s laws and the scope of practice for the NPPs you employ. 

Example: Medicare requires only general physician supervision for a chest X-ray, but Florida law requires a physician-owned practice to provide direct supervision, regardless of payer (Patient Self Referral Act of 1992), warns Jean Acevedo, LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Fla.

“With the myriad of laws and regulations that have to be considered for a health care provider to be compliant (and not at risk for recoupment of previously paid claims), it’s easy to get confused,” Acevedo adds. “In general, you are best served by following the most restrictive requirements.” In the example above, the Florida state law trumps Medicare’s more lenient requirements.

Reminder: Even for Medicare you need to be aware of state law and scope of practice rules. CMS does not consider a nonphysician practitioner (PA or ARNP) as an MD, therefore, supervision by a nonphysician practitioner does not qualify as physician supervision. However, if a specific test is within the practitioner’s scope of practice under state statute, the practitioner may bill for the services using her own Medicare provider identification number (PIN). Tests that require direct or personal supervision must have a physician (MD or DO) presence and documentation in the medical record should include the physician signature or a sentence agreeing with the NPP service of care. 

Erase Confusion With Detailed Documentation

CMS is vague about how you can demonstrate you’re not breaking the rules, but you do want to be sure documentation adequately demonstrates that the required physician supervision was furnished. It’s generally up to the supervising physician and the NPP to make sure the documentation is in place. 

Try this: Experts advise following these steps for documentation to keep you on the right track:

• Make sure the employer’s files for each provider performing general (level-one) supervision diagnostic tests contains a note indicating that the particular provider is fully trained for the procedure.
• Put a printout of the procedure results in the patient’s chart.
• For procedures requiring direct (level-two) and personal (level-three) supervision, make sure the progress notes contain a comment and/or signature by the supervising physician that she was immediately available to furnish assistance (for direct) or present in the room (for personal) during the performance of the test. When the NPP writes a statement saying that she performed the test under the physician’s direct or personal supervision, the documentation must include a signature by the physician agreeing with the NPP statement.