Pulmonology Coding Alert

Can you differentiate general supervision from direct?

Supervision can be a tricky issue, particularly when you’re trying to determine whether a service is billable when the pulmonologist isn’t in the office.

A subscriber wrote to Pulmonology Coding Alert and asked what the required supervision rules are for the following codes:

• 94617 -- Exercise test for bronchospasm, including pre- and post-spirometry, electrocardiographic recording(s), and pulse oximetry)
• 94618 -- Pulmonary stress testing (eg, 6-minute walk test), including measurement of heart rate, oximetry, and oxygen titration, when performed).

Here’s the scoop: To find the supervision rules, check out Medicare Physician Fee Schedule (MPFS) tool, where you’ll see that both codes have Physician Supervision indicator 9 (not applicable) for the global and professional component, but for the technical component they have indicator 1, which means general supervision.

The MPFS notes supervision levels in number format (such as 01, 02 and so on). You can find supervision level explanations in Medicare’s IOM 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 80. Following is a checklist of the supervision levels you might see in there.

The supervision rules only apply to the technical portion of the service (including TCs billed globally with the professional component of the procedure), advises Carol Pohlig BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. “It is important to note that CMS only permits a physician (MD/DO) to provide the required supervisory component for diagnostic testing. NPs, PA-Cs, and CNSs are permitted to bill globally for tests that they personally perform and interpret, within the context of their State Scope of Practice and Delineation of Privileges.”

Physician Supervision/Diagnostic Indicator (Phys Supv)

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. For example, most payers 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. Examples of procedures requiring direct supervision include certain CT scans and several other procedures.

Level 03 is personal supervision.

What this means: The physician must be in attendance in the room during the procedure.

Sources: MPFS lookup tool: >https://www.cms.gov/apps/physician-fee-schedule/search/search-results.aspx?Y=0&T=1&HT=1&H1=94617&H2=94618&M=5.

Indicator definitions (page 29): https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/How_to_MPFS_Booklet_ICN901344.pdf.