Health Information Management

Physician supervision requirements also apply to diagnostic services

JustCoding News: Outpatient, October 21, 2009

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

Editor’s note: This is the first article in a two-part series. Part one addresses the physician supervision requirements for diagnostic services. Part two will examine strategies to help provider-based departments handle the requirements.

Many facilities are familiar with the physician supervision requirements for therapeutic services, but CMS’ physician supervision requirements don’t end there.

In fact, physician supervision is required for all diagnostic tests so the facility can be reimbursed by CMS, says economic analyst at the American College of Radiology (ACR) in Helen Olkaba, MS, Reston, VA.

“In general, the challenge is being able to ensure quality of care without disrupting the way patient care is being provided,” Olkaba says.

Ambiguous CMS regulations
Some regulation areas remain unclear, even after CMS attempted to clarify the requirements in the 2008 and 2009 hospital outpatient prospective payment system (HOPPS) final rules, Olkaba says.

For example, it is not clear how hospitals will be able to meet the supervision requirements when dealing with a large number of trauma patients in emergency departments (ED), especially after hours, Olkaba says. The ACR is also reviewing how the supervision rule affects teleradiology services because geographic distance can prevent adequate coverage by the supervising physician.

The lack of clarity in the physician supervision regulation has affected the general understanding of the regulation. Even the actual effective date of these requirements for hospital outpatient settings is not clear. Before the 2009 OPPS final rule, healthcare facilities generally understood that supervision rules were only applicable in the office, Olkaba says.

“CMS failed to clearly indicate whether these requirements applied to services furnished in a department of a hospital that is located on the campus of that hospital in the 2000 HOPPS final rule,” she says. “Consequently, many stakeholders interpreted the HOPPS final rule to mean that the physician supervision requirements for diagnostic tests applied only to entities with provider-based status located off the campus of the main provider.”

According to CMS:

‘Direct supervision’ means the physician must be present and on the premises of the location and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. (73 Federal Register 68702

In addition, in the 2010 HOPPS proposed rule, CMS suggests allowing nonphysician practitioners (e.g., nurse practitioners, clinical nurse specialists, and physician assistants) to supervise all therapeutic services, as long as it is in their scope of practice and state laws allow it.

For diagnostic tests, the rule states that nonphysician practitioners may not function as supervisory physicians. However, they may perform diagnostic tests under their own statutory benefits and their state’s requirement for physician supervision, Olkaba says.
The supervision levels for diagnostic services follow the levels of general, direct, or personal supervision, as listed in the Medicare physician fee schedule (MPFS) relative value units (RVU) table. Access MPFS RVU tables.

Freestanding clinic challenges
Freestanding clinics and provider-based departments face similar challenges because the supervision rules are applicable in all settings. However, freestanding clinics don’t have the luxury of having additional physicians just a call away.

“We can’t just call a code blue and have somebody run from next door,” says Valerie Andolina, imaging and compliance manager at Elizabeth Wende Breast Care in Rochester, NY. As a consequence, its providers do not perform any diagnostic services unless a physician is present in the facility, Andolina says. That way, if something does happen, the physician can decide whether the patient must be taken to the ED or just needs some Benadryl for an allergic reaction.

“We would prefer to play it safe, but we also have to figure in that there is a shortage of these doctors,” says Andolina. “Some of the work is going to be performed by the technologist prior to the radiologist entering the room.”

Ambulatory surgery centers must ensure that the supervising physician isn’t in surgery the entire time.

“It is not clear how the supervision requirements affect facilities in rural settings where there is a shortage of physicians,” Olkaba says. “Imposing higher levels of supervision requirements may affect access to care.”

Independent diagnostic testing facilities (IDTF) have stringent supervision requirements to deal with compared to the other settings, which makes it a little different, Olkaba says. For example, the supervising physician’s qualifications are determined locally through a local coverage determination. Some states also have more stringent requirements for the credentialing of supervising physicians for IDTFs.

Scheduling difficulties
Some facilities are already running into a scheduling crunch because of the requirements. For example, Elizabeth Wende Breast Care has a waiting list for diagnostic procedures.
“Because we’re a standalone place and it’s a private doctor’s office, we only see patients when the doctors are here,” Andolina says. “Our challenge is having enough doctors available for our patients because [breast imaging specialists] are so rare.”

The physicians at Andolina’s facility not only perform the diagnostic breast imaging, but also read all the screening mammograms performed at the facility. Making sure a physician is always present and available is a challenge, but one Andolina says is important to overcome.

“We don’t want to do anything that could put the patient at risk,” she says.
In fact, the center does not perform any invasive diagnostic procedures unless a radiologist is present. The facility will sometimes perform screening mammograms without a physician present.

“We are probably more aware of the risks because of our situation of not being in a hospital,” Andolina says. “These are our doctors and there are only some many of them. At least one doctor has to be here in order for us to do these exams.”

Efficiency is crucial to meeting patient demand and physician supervision requirements, she says.

At Elizabeth Wende, technologists do everything they can before the physicians step into the room. That way, the physicians aren’t handling any paperwork or setup.

“Efficiency is very important,” Andolina says. “Otherwise, we would never be able to see all of the patients we need to see.”

Action plan to tackle requirements
So how can your facility ensure compliance with the physician supervision requirements? One place to start is by developing internal policies with protocols that enable physicians to be in compliance with the supervision regulation, says Olkaba.

Facilities also need to make sure they retain documentation of the actual supervision in the patient’s report or somewhere in the facility, in case of an audit. In addition, facilities should retain documentation of their Medicare Administrative Contractor’s (MAC) supervision requirements to show what was required at the time the service was provided, as MACs tend to update these from time to time, Olkaba says.

The ACR recommends that radiologists work with their hospital administrators to ensure that they are in compliance with all Medicare supervision requirements.

“Radiologists need to develop guidelines that attempt to define principles of practice that should generally produce high quality of care,” Olkaba says.

Editor’s note: E-mail Olkaba at

E-mail Andolina at

This story was originally published in the October issue of Briefings on APCs.

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

Most Popular