Cardiology Coding Alert

Nonphysician practitioners (NPPs) who perform echocardiograms and other ultrasound procedures require only general supervision, according to revised guidelines on physician supervision of diagnostic tests published by HCFA in an April 19 program memorandum. Cardiovascular stress tests, however, continue to require the presence of a physician in the office (but not in the same room).

The implementation date for the revised guidelines is July 1, 2001. Local Medicare carriers are expected to apply the rules unless state scope-of-practice laws or regulations further limit the role of technicians, nurses or other NPPs in performing specific services.

Note: A complete list of the affected CPT codes and their supervision levels can be downloaded at www.hcfa.gov/pubforms/transmit/B0128.pdf.

This announcement has been anticipated for more than three years. HCFA issued its first physician supervision guidelines, which required physician supervision for most diagnostic tests, in the Oct. 31, 1997, Federal Register. Until then, supervisory requirements applied to diagnostic tests were not clearly defined.

The guidelines which are unchanged in the latest program memorandum include three levels of physician supervision:

General Supervision means the procedure is furnished under the physicians overall direction and control, but his or her presence is not required during the procedure. In addition, the training of nonphysician personnel who perform diagnostic procedures and maintain the necessary equipment and supplies is the physicians continuing responsibility.

Direct Supervision in an office setting means the physician must be present in the office suite and be immediately available to furnish assistance and direction throughout the procedure. The physician is not required to be present in the room where the procedure is performed.

Personal Supervision means the physician must be physically present during the procedure.

Under the October 1997 regulations, diagnostic tests payable under the physician fee schedule including cardiovascular services such as ECGs, echos and stress tests required one of these levels of physician supervision.

Although the regulations went into effect Jan. 1, 1998, they were withdrawn 27 days later because of issues raised about the level of supervision required for some specific diagnostic services (such as ultrasound), according to a Jan. 28, 1998, HCFA memorandum to regional administrators.

Ultrasound procedures such as echos, although originally calling for general supervision, required direct supervision under the October 1997 Final Rule. This prompted complaints from cardiologists and other physicians who routinely used technicians for the technical portion of echocardiography and believe that requiring the physician to be in the office during the test was unnecessary and limited their ability to see other patients.

The Jan. 28, 1998, memorandum instructed carriers to continue to follow their existing policies on physician supervision of diagnostic tests until HCFA provided further instruction which the latest memorandum does.

Under the revised guidelines, ultrasound procedures still require only general supervision. This is welcome news for cardiology practices. Direct supervision requirements for echos would have required a huge operational change, says Gay Boughton-Barnes, CPC, MPC, CCS-P, chief medical compliance officer for the University of Oklahoma Medical Center in Tulsa. Instead of being in the hospital performing procedures, one cardiologist in the practice would have to be in the office whenever an echo was performed.

The revised guidelines also confirm that only direct supervision is required for stress tests (the 1998 guidelines had indicated that personal supervision was required). Other services, such as the technical component of electrocardiograms and many radiologic services, remain under general supervision.

PAs and NPs Are Exempt

The supervision guidelines do not apply to physician assistants (PAs), nurse practitioners (NPs) and clinical nurse specialists (CNSs) when they perform a service within their scope of practice, says Michael Powe, director of reimbursement with the American Academy of Physician Assistants in Bethesda, Md. According to Powe, any such service, regardless of the supervision level required by other NPPs, requires the equivalent of general supervision only when performed by a PA, NP or CNS. He cites a statute of the Code of Federal Regulations, 42CFR410.32, which states:

NPPs [clinical nurse specialists, clinical psychologists, clinical social workers, nurse-midwives, nurse practitioners, and physician assistants] who furnish services that would be physician services if furnished by a physician, and who are operating within the scope of their authority under state law and within the scope of their Medicare statutory benefit, may be treated the same as physicians treating beneficiaries.

Because the HCFA memo does not specifically state that the regulations dont apply to this group of NPPs, Powes organization wants HCFA to issue a disclaimer to that effect.

Incident to Does Not Apply to Diagnostic Tests

Since 1998, PAs and NPs have been able to bill for their services using their own universal personal identification numbers (UPIN). Medicare reimburses such claims at 85 percent of the rate paid to physicians. However, if the physician is present in the office, services performed by other NPPs who do not have billing numbers, such as technicians and nurses, can be billed incident to (assuming the NPP has the scope of practice to perform the service). Because Medicare treats such claims as though they were performed by the physician, the procedure or service can be billed at 100 percent of the fee schedule. NPs and PAs may also bill incident to if the physician is present.

Under Medicares incident to guidelines, the procedure or service must be under the direct personal supervision of the physician, which requires the physician to be in the office but not in the same room as the NPP performing the service.

Incident to guidelines apply to physician services only, not diagnostic tests, says Wayne Powell, director of regulatory and legal affairs for the American College of Cardiology. As evidence, he cites relevant sections of the Social Security Act (1861.s.1) and the Code of Federal Regulations (42CFR410.10).

The Medicare Carriers Manual, furthermore, exempts certain diagnostic tests from incident to supervision requirements, stating that these procedures may be performed by technicians as long as the technicians general supervision and training, as well as the maintenance of the necessary equipment and supplies, are the continuing responsibility of a physician.

Although HCFA has yet to publish a list that clearly differentiates between physician services and diagnostic tests, if the CPT code for the service is listed in the revised diagnostic test guidelines and has been assigned a level of supervision, it likely does not belong in the physician services category, and incident to guidelines such as direct personal supervision should not apply.

Note: The new requirements apply to diagnostic tests performed in office settings or by independent diagnostic test facilities, but not to those performed in hospital inpatient units or hospital outpatient clinics.