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Neurology & Pain Management Coding Alert

Don't Get Derailed by Supervision Requirements

Published on Sun Jan 02, 2005

Understand supervision levels and note physician involvement for success

To demonstrate to payers that you're following physician supervision requirements for your nonphysician staff, be sure to include a note in your documentation demonstrating the neurologist's involvement.

First, Know the Requirements

In most cases, if the neurologist 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 nonphysician staff varies by procedure.
 
CMS has designated three principle levels of physician supervision:
 

  • Level one: general supervision. "General supervision means the procedure is furnished under the physician's overall direction and control," says Maggie M. Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates 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 maintaining the testing equipment.

    Examples of services requiring general supervision include sleep testing 95805 and 95808 and electro-encephalography (EEG) procedures 95812 and 95819.
     
  • Level two: direct supervision. This means that in the office setting the neurologist must be present in the office suite and immediately available to furnish assistance and direction throughout the procedure. The neurologist doesn't need to be present in the room during the procedure.

    Examples of procedures requiring direct supervision include autonomic function testing (95921) and EEG during nonintracranial surgery (95955).
     
  • Level three: personal supervision. In this case, the neurologist must be present in the room during the procedure to offer hands-on assistance and direction.

    "For a level-three service, the neurologist must be physically in the room with the patient and the NPP [nonphysician practitioner] 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 ischemic limb exercise testing (95875) and Wada activation test for hemispheric function (95958).

    Here's a tip worth remembering: You can find the required supervision levels for all codes by looking to column "Z" ("Physician Supervision of Diagnostic Procedures") of the Physicians Fee Schedule database.

    Next, Put It All in Writing

    CMS is vague about how you can demonstrate you're not breaking the rules. The policy says only, "Documentation maintained by the billing provider must be able to demonstrate that the required physician supervision is furnished." Therefore, the billing parties must make sure the documentation is in place.

    To shore up your documentation, follow these tips:

    1. Make sure the employee file of any nonphysician practitioner who performs general (level-one) supervision diagnostic tests contains a note indicating that he is fully trained for the procedure.

    2. Place a printout of the procedure results in the patient's chart.

    3. For procedures requiring personal (level-three) supervision, make sure the progress notes contain a comment or signature by the supervising neurologist.

    4. If tip 3 (above) proves impossible, the NPP should write a statement saying that he performed the test under the neurologist's personal supervision.

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