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Although the regulations went into effect Jan. 1, 1998, they were withdrawn 27 days later because of issues raised about the level of supervision required for some specific diagnostic services (such as ultrasound), according to a Jan.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