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Optometry Coding & Billing Alert

Document Supervision Levels Or Face Denials for Diagnostics

Published on Sun Sep 19, 2004

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If the techs in your office are performing diagnostic ophthalmological services, you know that they need to be supervised by an optometrist. But keeping track of what Medicare defines as supervision, let alone what tests require what 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."

Get Personal, Direct or General

CMS has defined three levels of physician supervision of diagnostic tests:

 

  •  Level one: Procedure must be performed under the general supervision of a physician. "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.

     
  •  Level two: Procedure must be performed under the direct supervision of a physician. The physician must be present in the office suite and immediately available to assist in and direct the procedure.

     
  •  Level three: Procedure must be performed under the personal supervision of a physician. The physician must be present in the room during the diagnostic testing procedure.

    Note: There are now no ophthalmological tests that require level-three supervision.

    CMS also designated supervision levels four, five and six to be specific to the practices of psychology, audiology and physical therapy, respectively. You can find the supervision levels for each CPT code in column Z ("Physician Supervision of Diagnostic Procedures") of the Physicians Fee Schedule database.

    For the required physician supervision levels for special ophthalmological services, see "Quick Key: Supervision Levels for Ophthalmological Diagnostic Tests" on page 70.

    Get It All in Writing

    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, says Peggy Dubay, billing manager for Anderson Hills Eye in Cincinnati.

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

     

  •  Make sure the employee file of any nonphysician practitioner who performs general (level-one) supervision diagnostic tests contains a note indicating that they are 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.
     
  •  If this is impossible, the NPP should write a statement saying that he performed the test under the physician's personal supervision.

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