Knowledge Base Article

Q:

How do you determine the level of physician supervision required for hospital outpatient therapeutic and diagnostic services?

A:

The answer is sort of like putting together a jigsaw puzzle. There is a piece here and a piece there. Terms defined in one place, then defined further in another place, codes in the physician RVU file, and a new type of service supervision designation altogether. Let’s see if we can put the pieces in place.

Definitions

Definitions of the levels of supervision can be found in the Code of Federal Regulations at 42 CFR 410.32 (b).

• General supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure.
• Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. CMS has further defined direct supervision for services provided in a hospital in the Medicare Benefit Policy manual, chapter 6, sections 20.4 and 20.5 as noted below.
• Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

This section of the CFR also discusses some exceptions to diagnostic supervision requirements such as mammography services, audiology tests, laboratory tests, and a few other exceptions.

In the Medicare Benefit Policy manual, CMS clarifies the definition of “direct supervision” as it relates to hospital services performed during or after CY 2011 – “whether directly or under arrangement in the hospital or in an on-campus or off-campus outpatient department of the hospital as defined at 42 CFR 413.65, “direct supervision” means that the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure. As discussed below, the physician is not required to be present in the room where the procedure is being performed or within any other physical boundary as long as he or she is immediately available…. Immediate availability requires the immediate physical presence of the supervisory physician. CMS has not specifically defined the word “immediate” in terms of time or distance; however, an example of a lack of immediate availability would be situations where the supervisory physician is performing another procedure or service that he or she could not interrupt. Also, for services furnished on-campus, the supervisory physician may not be so physically distant on-campus from the location where hospital outpatient services are being furnished that he or she could not intervene right away. The hospital or supervisory physician must judge the supervisory physician’s relative location to ensure that he or she is immediately available… The supervisory physician must have, within his or her State scope of practice and hospital-granted privileges, the knowledge, skills, ability, and privileges to perform the service or procedure… The supervisory responsibility is more than the capacity to respond to an emergency, and includes the ability to take over performance of a procedure or provide additional orders.”

Hospital Outpatient Diagnostic Services

The supervision requirements for hospital outpatient diagnostic services can be found in the Medicare Benefit Policy manual, chapter 6, section 20.4. Section 20.4.4 explains that supervision levels for individual diagnostic tests are listed in the quarterly updated Medicare Physician Fee Schedule (PFS) Relative Value File which can be found on the Medicare Physician RVU File webpage. After selecting the year and quarter (quarters identified by A (January), B (April), C (July), etc.), download the zip files, select the PPRRUV14 spreadsheet and locate the “Physician Supervision of Diagnostic Procedures” column (column Z in this year’s spreadsheets). Hospitals are interested in the designation for the technical component (TC) of diagnostic services. The supervision levels are listed by codes, the definitions of which can be found in the Medicare Benefit Policy manual, chapter 15, section 80. The main designations are:

• 1 - Procedure must be performed under the general supervision of a physician.
• 2 - Procedure must be performed under the direct supervision of a physician.
• 3 - Procedure must be performed under the personal supervision of a physician.
• 9 - Concept does not apply.

Certain diagnostic tests performed personally by non-physician practitioners (NPPs) do not require physician supervision but NPPs may not supervise diagnostic tests when performed by other hospital staff.

Hospital Outpatient Therapeutic Services

Section 20.5.2 of chapter 6 of the Benefit Policy Manual describes the supervision requirements for therapeutic services - all therapeutic services provided to hospital outpatients generally require direct supervision by an appropriate physician or NPP although CMS may assign a different level of supervision to some therapeutic services. In addition to physicians and clinical psychologists, licensed clinical social workers, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives may furnish the required supervision of hospital outpatient therapeutic services that they may personally furnish in accordance with State law and all additional rules governing the provision of their services. However, pulmonary and cardiac rehab services require that a physician provide the direct supervision.

CMS may designate certain services to general or personal supervision or beginning in 2011, as non-surgical extended duration therapeutic services. Extended duration services require direct supervision during the initiation of the service followed by general supervision for the remainder of the service at the discretion of the supervising practitioner. The service can transition to general supervision after the beginning portion of the service when the supervising practitioner decides the patient is stable enough for general supervision. The point of transition to general supervision must be documented in the patient’s progress notes or medical record. A list of “Hospital Outpatient Therapeutic Services Designated as General or NSEDTS” is available in the downloads section on the Hospital OPPS webpage.