Knowledge Base Article

When medical emergencies occur in public places, such as restaurants, movie theaters, or on airplanes, we often hear “is there a doctor in the house?” For certain diagnostic outpatient hospital procedures, Medicare wants to know if there is a doctor in the room. Descriptions of Medicare physician supervision requirements for both diagnostic and non-diagnostic services can be found in the Medicare Benefits Policy Manual, Chapter 6, sections 20.4 and 20.5.

Therapeutic Services

In 2010, CMS caused quite a ruckus when they “clarified” the physician supervision requirements for hospital therapeutic services. After several more clarifications, the final Medicare guidelines, from 2011 forward, for most hospital outpatient non-diagnostic services is “direct supervision” which means the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure. The physician does not have to be in the room, on the campus, or within any other physical boundary as long as he or she is immediately available. Other factors for “direct supervision” of therapeutic services are:

• 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.
• Immediate availability requires the immediate physical presence of the supervisory physician or non-physician practitioner.
• The supervisory physician or non-physician practitioner may not be performing another procedure or service that he or she could not interrupt.
• The supervisory physician or non-physician practitioner 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.

Diagnostic Services

The type of supervision required for diagnostic services furnished in an outpatient hospital setting is determined by the supervision levels listed in the quarterly updated Medicare Physician Fee Schedule (PFS) Relative Value File which can be found at PFS Relative Value Files. Select the appropriate year and quarter (A correlates to 1st quarter, B to 2nd quarter, etc.). You will want to select the spreadsheet that starts with PPRRVU. The pdf document in the folder explains the various designations within the file. For example, some of the definitions related to Physician Supervision of Diagnostic Procedures are:

• 01 = Procedure must be performed under the general supervision of a physician.
• 02 = Procedure must be performed under the direct supervision of a physician.
• 03 = Procedure must be performed under the personal supervision of physician.
• 09 = Concept does not apply.

See the complete document for explanations of all the assignments.

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 for outpatient hospital diagnostic services has the same requirements that are described above for direct supervision of therapeutic services except that diagnostic services require supervision by a physician. Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

As stated above, diagnostic services require supervision by a physician and in general may not be supervised by non-physician practitioners. There are exceptions that allow some diagnostic tests furnished by certain non-physician practitioners to be furnished without physician supervision. When these non-physician practitioners personally perform a diagnostic service they must meet only the physician supervision requirements for that type of practitioner when they directly provide a service. For example, nurse practitioners must work in collaboration with a physician, and assistants must practice under the general supervision of a physician. Non-physician practitioners, including physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives, cannot provide the required physician supervision when other hospital staff are performing diagnostic tests.

Hospitals need to be aware of the supervision requirements for diagnostic services, particularly those services that require personal supervision where the physician must be in the room during the performance of the procedure. There are over 200 CPT codes in the 2016 PFS RVU file that require personal supervision, with almost 150 of those being radiology procedures in the 70010-79999 CPT code range. This includes radiology procedures such as myelography, arthrography, angiography and venography, among others. Medicare allows payment for diagnostic services only when those services are furnished under the appropriate level of supervision.

Hospitals need to ensure that venograms, arthrograms and other relevant radiology services are only performed when a physician is in the room. Lack of appropriate supervision can result in an inappropriate Medicare payment. When personal supervision is required, there must be “a doctor in the room.”