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Otolaryngology Coding Alert

Nonphysician Practitioner Coding:

Ensure Proper Payment for Audiology and Allergy Testing

Published on Sat Jun 01, 2002

The level of supervision required for audiology and allergy tests performed by nonphysician practitioners (NPPs) varies depending on two factors: the type of test performed and the credentials of the NPPs performing the test.

Otolaryngologists and their coders frequently confuse physician supervision guidelines for diagnostic tests. It is easy to see why, notes Susan Callaway, CPC, a coding and reimbursement specialist and educator in North Augusta, S.C. "Both sets of guidelines have a lot in common," she says. "Not only do both guidelines apply to services performed by NPPs, but they also involve supervision by a physician."

In addition, an inexperienced coder may not be certain how to distinguish a diagnostic procedure, such as endoscopy or biopsy, from a diagnostic test, such as audiometry or allergy tests.

The distinction is important because there are major differences between the "incident to" and diagnostic test guidelines. To determine the correct level of physician supervision for a given service, otolaryngologists need to know how to identify what Medicare considers a diagnostic test and what supervision level is required.

Physician Supervision of Diagnostic Tests

An extensive list of diagnostic tests is payable under the Physician Fee Schedule (PFS). These tests can be identified reasonably accurately by the number of global days in the surgical package, which is noted in field N of the national PFS Relative Value Guide. Further, an April 2001 program memorandum (Transmittal B-01-28) from CMS listed many diagnostic test codes requiring at least some physician supervision. The list includes many diagnostic tests performed by otolaryngologists, such as:

  • Most audiologic tests from 92552 to 92596
  • Most allergy tests from 95004 to 95065
  • Vestibular function tests with recording, 92541-92548.

    Note: Other diagnostic procedures, such as diagnostic endoscopies or biopsies, are not considered tests, and the guidelines do not apply.

    Unlike incident to guidelines, which require "direct personal supervision" of an NPP while a procedure or service is performed, diagnostic test guidelines include three levels of supervision:

  • General: The procedure is furnished under the physician's overall direction and control, but the physician's presence is not required. Under general supervision, the training of the nonphysician personnel who perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.
  • Direct: The physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. The physician does not have to be present in the room where the procedure or service is performed.
  • Personal: The physician must be in the room during the performance of the procedure.

    Note: The direct personal supervision requirement for incident to billing corresponds to direct supervision for a diagnostic test.

    Codes listed in the memorandum for which general supervision only is required are listed with a "1"; those requiring direct supervision, a "2"; and for personal supervision, "3." Allergy tests require either direct or personal supervision (in case the patient has an anaphy-lactic reaction to a test).

    Audiology and vestibular function tests are listed with a "5." According to the Medicare transmittal, "physician supervision policy does not apply when [these] procedures [are] personally furnished by a qualified audiologist; otherwise [when performed by other NPPs, these tests] must be performed under the general supervision of a physician." If an audiologist performs the test, physician supervision requirements do not apply (unless your state has unusual scope-of-practice legislation).

    Note: Only three of the audiology tests listed 92585, 92587 and 92588 are split into professional and technical components. According to the CMS memorandum, the audiologist may report the global code (both the technical and professional component) or technical component. The professional component, presumably, remains for the otolaryngologist to perform personally.

    Allergy tests, meanwhile, require direct (2) or personal (3) supervision because the patient can have a severe reaction when test shots are administered and may require emergency life-saving treatment. Codes 95004, 95024, 95027, 95028, 95044, 95052 and 95056 require direct supervision, whereas 95060, 95070, 95071, 95075 and 95078 require personal supervision, with the otolaryn-gologist in the room while the test is performed.

    Allergy shots, however, are not diagnostic tests, and when administered by an NPP, incident to guidelines apply (state scope-of-practice laws permitting).

    Note: Two codes 95010 (Percutaneous tests [scratch, puncture, prick] sequential and incremental, with drugs, biologicals or venoms, immediate type reaction, specify number of tests) and 95015 (Intracutaneous [intradermal] tests, sequential and incremental, with drugs, biologicals, or venoms, immediate type reaction, specify number of tests) were not included in the CMS list.

    These physician supervision guidelines apply to Medicare carriers as long as the state's scope-of-practice laws or regulations permit NPPs to perform these duties. For high-level NPPs physician assistants (PA), nurse practitioners (NP) and clinical nurse specialists (CNS), among others only general supervision is required unless state law rules otherwise, says Michael Powe, director of reimbursement with the American Academy of Physician Assistants in Bethesda, Md.

    According to Powe, any allergy testing service, regardless of the supervision level required by other NPPs, requires only the equivalent of general supervision when performed by a PA, an NP or a CNS. He cites the Code of Federal Regulations (42 CFR 410.32), which states: "Nonphysician practitioners (that is, clinical nurse specialists, clinical psychologists, clinical social workers, nurse-midwives, nurse practitioners, and physician assistants) who furnish services that would be physician services if furnished by a physician, and who are operating within the scope of their authority under State law and within the scope of their Medicare statutory benefit, may be treated the same as physicians treating beneficiaries."

    Note: A complete list of the affected CPT codes and their supervision levels can be downloaded at www.hcfa.gov/pubforms/transmit/B0128.pdf.

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