Cardiology Coding Alert

Learn what to do when another provider does supervision

Supervision levels can make or break your claim, so you have to know what supervision level your cardio procedures require -- or you could face denials.
 
If the nurse practitioners in your office perform SPECT studies, you know that they generally include a stress test that demands direct supervision -- a potential problem for payers. Keeping track of what Medicare defines as supervision in cases like these, let alone what tests require what levels of supervision, can be daunting.

Not following Medicare's rules for diagnostic test supervision may lead to claim denials. CMS' policy states that certain diagnostic tests must be supervised "to be considered reasonable and necessary and, therefore, covered under Medicare."

Follow these three expert steps, and you'll be certain your claims are rock-solid and reimbursement is on its way.

Step 1: Perfect These Supervision Basics

First, you must understand each level of supervision.

Where to find them: The Medicare Physician Fee Schedule supervision indicators show the physician supervision level required for a diagnostic test if it's performed in a physician office, imaging center or independent diagnostic testing facility (IDTF). Important: These rules don't apply to diagnostic tests performed in an inpatient or outpatient hospital setting.

You have three supervision indicators to learn: 01, 02 and 03.

General: Level 01 is general supervision. What this means: The physician must provide direction and control during the procedure, but the service doesn't require the physician's presence. For example, most payers only require general supervision during plain films, most ultrasounds, and CT or MRI without contrast.

Direct: Level 02 is direct supervision. What this means: 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. "Most conferences and seminars I've been to tell us to refer to this as 'hollering distance.' If you can call for help and the physician can hear you, this qualifies," says Sandy Fuller, CPC, compliance officer at Cardiovascular Associates of East Texas in Tyler.

Examples of procedures requiring direct supervision include exams using intravenous contrast, cardiovascular stress tests and pacer monitoring, with the exception of antitachycardia pacemaker interrogations (93724, Electronic analysis of antitachycardia pacemaker system [includes electrocardiographic recording, programming of device, induction and termination of tachycardia via implanted pacemaker, and interpretation of recordings]). Code 93724 has a technical component that requires personal supervision.

Personal: Level 03 is personal supervision. What this means: The physician must be in attendance in the room during the procedure. Examples include heart catheterizations, transesophageal echocardiograms and 93724.

Step 2: Erase Blurred Lines for Good

Determining supervision levels may seem clear-cut, but you may find that procedures are sometimes vague as to what level of supervision they require.

Example: Your cardiologist performs a tilt-table test (93660, Evaluation of cardiovascular function with tilt-table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention). You think the cardiologist doesn't need to be present during the tilt-table test because of the low risk to the patient, but your colleague says most carriers require the cardiologist to be physically in attendance or close by should a problem arise.
While you two may debate personal supervision versus direction supervision, a little investigation into the Physician's Fee Schedule will solve the issue. Although 93660 used to have a personal supervision requirement, the Fee Schedule clearly shows that 93660 requires direct supervision.

Protect yourself: If you're confused about supervision requirements for various procedures, you should look to the Physician Fee Schedule.

Step 3: Know Who Provides Supervision

Another area of confusion happens when another provider in your practice, such as a nurse practitioner, performs a procedure instead of your cardiologist. How should you handle supervision requirements? Taking the time to figure out what you should do now will save you the hassle in the future.

Example 1: Your practice is opening a nuclear imaging department so your cardiologist can order more SPECT studies on patients each day. Your nurse practitioner mentions that these services are in her scope of practice, but you have a snag. SPECT studies typically include a stress test (93015, Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous echocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report) to facilitate imaging during stress as well as rest.

Stress tests have a "direct" physician supervision requirement as defined by Medicare, so a physician must be in the office or suite and available to assist should the need arise.

Solution: You should be OK. This supervision requirement applies only in the office and only if a technician performs the stress test. If the nurse practitioner personally administers the stress test, you would not need to worry about this supervision requirement.

Also, don't forget to take into account the location of the procedure.

Example 2: Your practice performs its SPECT studies in a hospital. Again, your nurse practitioner says this service is within her scope of practice.

Solution: Remember, supervision levels don't apply if a procedure takes place in an inpatient or outpatient hospital center. "If your nurse practitioners have privileges to perform the test at a facility, then they should also be able to bill for it under their UPIN," says Cheryl Klarkowski, RHIT, a coder at BayCare Health System LLC in Green Bay, Wis.

Want to know more? Send your toughest supervision requirement quandaries to editor Suzanne Leder at suzannel@eliresearch.com, and you may see them answered in Cardiology Coding Alert's 2007 issues.