Internal Medicine Coding Alert

Code requires personal supervision? Make sure the doctor is in the room

Supervision levels can make or break your reimbursement, so you have to know which supervision level your internist's procedures require, or you could face denials or subject your practice to an audit.

If the practitioners in your office perform stress tests, you should know that these procedures demand direct supervision -- a potential problem if someone other than the physician is monitoring the patient. Keeping track of what Medicare defines as supervision in cases like these, as well as which tests require the particular 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

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.

First, you must understand each level of supervision, because the Fee Schedule lists them in number format (such as "01," "02," and so on). You can find explanations of the supervision levels in Medicare's IOM 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 80, says Kathy Pride, CPC, director of government program services with QuadraMed in Reston, Va. These levels of supervision are part of the physician fee data base, and each CPT code is assigned a level of supervision.

Medicare refers to twelve different supervision levels, but five of the levels are the most relevant to internists, as follows:

Level 0 or 09: Procedures listed in these categories are not subject to the supervision requirements.

Level 01 refers to general supervision. What this means: The physician must provide direction and control during the procedure, according to Section 2070 the MCM. "The physician wouldn't be required to be in the room," says Shelley Bellm, CPC, coder at Colorado Mountain Medical. For example, most payers only require general supervision during plain x-ray films.

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. Many consultants refer to this as "hollering distance."

Examples of procedures requiring direct supervision include cardiovascular stress tests (93015-93017) and allergy tests (such as 95024-95056).

Level 03 is personal supervision. What this means: The physician must be in attendance in the room during the procedure. For example, you must perform a stereotactic breast biopsy (77031) under personal supervision.

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 which level of supervision they require.

Example: Your practitioner evaluates a patient's use of her metered dose inhaler (94664, Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device). You think the internist doesn't need to be present during the inhaler evaluation test because of the low risk to the patient, but your colleague says most carriers require the internist 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 Medicare's Physician Fee Schedule will solve the issue. The fee schedule clearly shows that 94664 requires direct supervision, so the physician does not need to remain in the room during the procedure, but must be in the suite and immediately available.

Step 3: Identify Who Provides Supervision

Another area of confusion happens when a different  provider in your practice, such as a nurse practitioner, performs a procedure instead of your internist. 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 has recently ordered new cardiovascular testing equipment so your internist can perform more in-depth exams of patients each day. Your nurse practitioner mentions that these services are in her scope of practice, but you have a snag. Stress tests (93015, Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report) 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.

According to the MCM, although nonphysician practitioners (NPPs) cannot serve as the "supervising physician" of other practitioners during diagnostic tests, NPPs may personally perform such diagnostic tests, in accordance with their state laws and scopes of practice. In these instances, remember to bill under the NPP's provider number and not the physician's.

Also, don't forget to take into account the location of the procedure. 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, they should also be able to bill for it under their UPINs.