Cardiology Coding Alert

Keep Medicare's direct physician supervision rule in mind.

The Reader Question "93016 NPI Depends on Provider" in Cardiology Coding Alert, vol. 15, no.4, stated that you should use the nurse practitioner's National Provider Identifier (NPI) to bill 93016 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report) when the nurse practitioner (NP) provides the 93016 service and state scope of practice allows her to provide that service without direct physician supervision.

To clarify, practices should consider the relevant rules regarding physician supervision of diagnostic tests when deciding how to perform and report these tests. The guidance cited below suggests that if there is no physician providing direct supervision during the test, the NP may bill the test under her own NPI in the very limited circumstances where the NP performs the test and state scope of practice and state supervision requirements allow an NP to perform the test.

Review the MBPM, CFR, and More

Take note of Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 80, which gives the basic rule that diagnostic tests generally require physician supervision: "Section 410.32(b) of the Code of Federal Regulations (CFR) requires that diagnostic tests covered under §1861(s)(3) of the Act and payable under the physician fee schedule, with certain exceptions listed in the regulation, have to be performed under the supervision of an individual meeting the definition of a physician (§1861(r) of the Act) to be considered reasonable and necessary and, therefore, covered under Medicare."

Section 80 goes on to say that NPs don't qualify as physicians (and so can't be supervisory physicians), but NPs may perform certain diagnostic tests if the state allows it: "Nurse practitioners, clinical nurse specialists, and physician assistants are not defined as physicians under §1861(r) of the Act. Therefore, they may not function as supervisory physicians under the diagnostic tests benefit (§1861(s)(3) of the Act). However, when these practitioners personally perform diagnostic tests as provided under §1861(s)(2)(K) of the Act, §1861(s)(3) does not apply and they may perform diagnostic tests pursuant to State scope of practice laws and under the applicable State requirements for physician supervision or collaboration" (www.cms.gov/manuals/Downloads/bp102c15.pdf).

In other words, NPs cannot provide direct physician supervision, which Medicare essentially defines as in the office suite and available to assist during the service. For direct supervision, the physician takes full responsibility for that service and cosigns documentation created by the NP. However, if the state scope of practice laws and state requirements for working with the physician (supervision and collaboration) allow NPs to perform a particular service without a physician taking full responsibility, then you may use the NP's NPI if the NP performed the service.

Additional information: To read more about NP services Medicare may cover, see MBPM, Chapter 15, Section 200.B. The above citations to the CFR and Social Security Act (the Act) mostly relate to exceptions to supervision requirements when the practice follows the specific state requirements authorizing the NP to perform the test. You'll find CFR section 410.32(b) at http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=%2Findex.tpl. Choose Title 42 and click Go, then choose the link for 400-413, and then choose the link for 410. To review section 1861(s)(2)(K) of the Act, head to www.ssa.gov/OP_Home/ssact/title18/1861.htm#act-1861.

Final note: Experts suggest that practices considering billing stress tests under an NP should review the legal implications of performing the test without direct physician supervision.