By Janice G. Jacobs, CPA, CPC, CCS, ROCC, and G. John Verhovshek, MA, CPC
The Centers for Medicare & Medicaid Services’ (CMS’) 2010 Outpatient Prospective Payment System (OPPS) Final Rule revised guidelines that define physician supervision of services performed in a hospital outpatient department, while leaving rules for services performed in free-standing centers/physician offices unchanged. The new guidelines, “Policies for Direct Supervision of Hospital and CAH Outpatient Therapeutic Services,” begin on page 264 of the final rule.
Resource Tip: View the 2010 OPPS Final Rule online at: http://edocket.access.gpo.gov/2009/pdf/E9-26499.pdf.
Midlevel Providers May Supervise Therapeutic Procedures
Under the 2010 OPPS Final Rule, CMS has broadened the rules for supervision of therapeutic procedures in the hospital outpatient setting to permit direct supervision by non-physician practitioners (NPPs), to include the following health care professionals:
- physician assistants (PAs)
- nurse practitioners (NPs)
- clinical nurse specialists (CNS)
- certified nurse-midwives (CNMs)
- licensed clinical social workers (LCSWs)
Eligible NPPs may supervise only those therapeutic services “that they may perform themselves under their state license and scope of practice and hospital-granted or CAH-granted privileges.” In other words, an NPP may supervise only those services he or she can perform personally under the applicable guidelines.
Therapeutic services falling under the new rules are those such as outpatient psychiatric group therapy, physical therapy (PT), speech therapy, and occupational therapy (OT).
For example, a LCSW may now supervise outpatient psychiatric group therapy sessions because he or she is qualified and trained to perform that service. That same LCSW may not prescribe medications or perform other services for which only the attending or other psychiatrist is qualified.
CMS guidelines define direct supervision to mean the supervising provider must be “immediately available to furnish assistance and direction throughout the performance of the procedure.” Specifically, “immediate availability” requires that:
The supervising provider must not be “performing another procedure or service that he or she could not interrupt.”
- The supervising provider must not be “so physically far away on the main campus from the location where hospital outpatient services are being furnished that he or she could not intervene right away.”
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- For therapeutic procedures performed on a hospital’s main campus, the supervising physician or practitioner must be present “on the same campus.” The supervisor may be located anywhere on the campus, including a physician’s office, an on-campus skilled nursing facility (SNF), or other nonhospital space.
- For therapeutic procedures performed in an off-campus provider-based department (PBD), the supervising physician or practitioner must be present in the PBD during the procedure.
- In addition to being able to provide the service/procedure under his or her state license, scope of practice, and hospital-granted or critical access hospital (CAH)-granted privileges, the supervising provider “must be prepared to step in and perform the service, not just respond to an emergency.”
A coding example of interactive group therapy provided by a LCSW would be CPT® code 90857 Interactive group psychotherapy billed on the CMS-1500 form under the LCSW’s own provider identification number (PIN).
Pay attention to payer requirements: Although these supervision guidelines apply specifically to Medicare patients/services, contractual ‘non-discrimination clauses’ with private payers may require hospitals (and participating physicians) to apply the same rules for all patients.
Diagnostic Services Specify Different Requirements
Supervision requirements for diagnostic services—such as computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, positron emission tomography (PET), ultrasound, and X-rays—differ from those for therapeutic services, as described above. NPPs may not supervise diagnostic tests provided to hospital outpatients. The required supervision can be provided only by a physician (MD or DO).
CMS guidelines specify, “All hospital outpatient diagnostic services provided directly or under arrangement, whether provided in the hospital, in a PBD of a hospital, or at a nonhospital location, follow the physician supervision requirements for individual tests as listed in the [Medicare Physician Fee Schedule] MPFS Relative Value File.”
In the Relative Value File, in the “Physician Supervision of Diagnostic Procedures” column, CMS assigns a physician supervision indicator to each CPT®/HCPCS Level II code representing a diagnostic service.
Resource Tip: The Relative Value File is available online at: www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/list.asp?listpage=4.
The indicators and definitions are:
| 0 |
Procedure is not a diagnostic test or procedure is a diagnostic test which is not subject to the physician supervision policy. |
| 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. |
| 4 |
Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist or a clinical psychologist or furnished under the general supervision of a clinical psychologist; otherwise must be performed under the general supervision of a physician. |
| 5 |
Physician supervision policy does not apply when procedure is furnished by a qualified audiologist; otherwise must be performed under the general supervision of a physician. |
| 6 |
Procedure must be performed by a physician or by a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical specialist and is permitted to provide the procedure under state law. |
| 6a |
Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may supervise another PT but only the PT with ABPTS certification may bill. |
| 7a |
Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may supervise another PT but only the PT with ABPTS certification may bill. |
| 9 |
Concept does not apply. |
CMS defines “general,” “direct,” and “personal” supervision requirements in the Medicare Benefit Policy Manual, chapter 15, section 80:
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. Under general supervision, the training of the non-physician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.
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 (for example, the physician must not be performing another procedure that cannot be interrupted, and must not be so physically far away that he or she could not provide timely assistance). This does not require that the physician must be present in the room when the procedure is performed, however.
Personal Supervision means a physician must be in attendance in the room during the performance of the procedure.
For example: The MPFS relative value unit (RVU) file assigns the technical portion of CPT® 77014 Computed tomography guidance for placement of radiation therapy fields a “2” physician supervision indicator. This means the service requires direct physician supervision when performed in the hospital radiology department, in a hospital-owned imaging center that is defined as a PBD, or in a physician office under arrangements with the hospital (that is, an outside imaging facility bills the hospital for exams it performs on hospital patients).