Medicare Compliance & Reimbursement

Caution: Denials and lost reimbursement could head your way if you ignore these guidelines.

Making appropriate use of your non-physician practitioners (NPPs) and ancillary staff will help keep your practice flowing smoothly. Knowing where your physicians are will enable you to bill supervision compliantly and keep reimbursements flowing.

If your medical assistant, physician assistant (PA), or nurse practitioner (NP) performs a diagnostic service outside of the required supervision, you may face denials and lost reimbursement. But keeping track of what supervisory levels Medicare requires for which services can be daunting. Read on to learn the basics and set your practice on the right course for proper reimbursement.

Important: Don’t confuse the supervision rules for diagnostic tests with the rules for billing “incident-to” services. While the levels are the same, the application is different.

Differentiate Requirement Levels

In most cases, if your physician does not directly provide all services a patient receives, you must nevertheless document a minimum level of physician supervision. The extent to which the physician must supervise ancillary staff varies by procedure.

CMS has designated three principal levels of physician supervision: general, direct, and personal.

Level 1 - General: For procedures that require general supervision, “the procedure is furnished under the physician’s overall direction and control,” says Maggie Mac, CPC, CEMC, CHC, CMM, ICCE, president of Maggie Mac Medical Practice Consulting in Clearwater, Fla. “But the physician’s presence is not required during the procedure. The physician must order the diagnostic test but does not have to be in the office at the time of the performance of the test.” The physician is responsible for training the people who do the tests, as well as for maintaining the testing equipment.

Examples of procedures your staff might perform that only require general supervision are venipuncture (36415), dip stick urinalysis (81002), and the technical component of echocardiograms (for example, 93306-TC).

Level 2 - Direct: With direct supervision, 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 your NPPs might perform that only require direct supervision include cardiovascular stress tests (93015-93017), auditory function tests (92620-92621), and certain MRI studies such as an abdominal MRI with contrast (74182, Magnetic resonance [e.g., proton] imaging, abdomen; with contrast material[s]).

Level 3 - Personal: For these procedures, the physician must be in attendance in the testing room during the procedure. “For a level-three service, the urologist must be physically in the room with the patient and the NPP providing the service. He or she cannot be across the hall with another patient or making phone calls at the front desk,” Mac stresses.

Examples of procedures that require personal supervision include complex speech evaluation (70371), certain radiology procedures such as a chest x-ray with fluoroscopy (71023), and ischemic limb exercise testing (95875).

Tip: CMS also designated supervision levels four, five and six to be specific to the practices of psychology, audiology and physical therapy, respectively. 

Pay Attention to State Regulations

While CMS assigns a required level of supervision for procedures and services as noted above, be careful you are not only following Medicare’s policy. You also need to be aware of your state’s laws and the scope of practice for the NPPs you employ.

Example: Medicare only requires general physician supervision for a chest x-ray, but Florida law requires a physician-owned practice to provide direct supervision, regardless of payer (Patient Self Referral Act of 1992), warns Jean Acevedo, LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Fla.

“With the myriad of laws and regulations that have to be considered for a health care provider to be compliant (and not at risk for recoupment of previously paid claims), it’s easy to get confused,” Acevedo adds. “In general, you are best served by following the most restrictive requirements.” In the example above, Florida state law trumps Medicare’s more lenient requirements.

Erase Confusion with Detailed Documentation

CMS is vague about how you can demonstrate you’re not breaking the rules; the policy says only that “documentation maintained by the billing provider must be able to demonstrate that the required physician supervision is furnished.” It’s generally up to the supervising physician and the NPP to make sure the documentation is in place.

Try this: Experts advise following these steps for documentation to keep you on the right track:

• Make sure the employer’s files for each provider performing general (level-one) supervision diagnostic tests contains a note indicating that the particular provider is fully trained for the procedure.
• Put a printout of the procedure results in the 
• patient’s chart.
• For procedures requiring personal (level-three) supervision, make sure the progress notes contain a comment or signature by the supervising physician that he was present in the room during the performance of the test, or the NPP should write a statement saying that he/she performed the test under the physician’s personal supervision.