Billing For Services Of Nonphysician Diagnostic Testing Category Has Its Own Set Of Supervision Guidelines

In the April issue we discussed the meaning of and requirements for ‘incident to’ billing for nonphysician practitioners (NPPs) and the related CMS supervision requirements. Diagnostic testing is a separate benefit category which has its own supervision guidelines that must be met in addition to those previously discussed.

NPPs, nurses and technicians are the principle providers of diagnostic tests. Accordingly, it is critical that practices understand and comply with the diagnostic test supervision requirements. These may be more or less stringent than the ‘incident to’ supervision guidelines. Failure to comply may result in denial of claims, payback of previously paid benefits and even exclusion of from participating in the Medicare program. Failure to comply may also trigger a violation of the Stark Law.

Effective July 1, 2001, CMS set forth revised levels of supervision required for diagnostic tests payable under the Medicare physician fee schedule. There are actually six levels, three of which are virtually the same as the three general services supervision levels and three which are directed to specific specialties. In its Transmittal B-01-28, issued April 19, 2001, CMS identified, by CPT code, those diagnostic services requiring specific supervision levels. Every practice should have a copy of this memorandum and be familiar with the supervision levels for those diagnostic tests performed in their office. This is available on the CMS Web site atwww.cms.hhs.gov/manuals/pm_trans/b0128.pdf.

An interesting aspect of these guidelines is that NPPs are not listed as supervising personnel. However, if it is within their state scope of practice, they can perform or supervise certain diagnostic tests if they are in the same room where the technical components of the tests are being administered by RNs or medical technicians, even if there is no physician in the office. If, for example, an NPP supervises a stress test and then provides the interpretation and report, he or she can bill 93015, reimbursable at 85{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}. This is allowable even through the 93015 CPT code description includes the phrase “with physician supervision.”

If, however, the NPP performs or oversees the test and a doctor interprets the result, the NPP would bill 93016 (stress test, supervision only) and 93017 (stress test, tracing only), and the doctor would bill interpretative code 93018. In this instance, the NPP would be paid 100{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the Medicare fees schedule for performing the technical component of the diagnostic test. CMS permits NPPs to perform diagnostic tests and bill for them under their own PINs (state law permitting).

This area is very gray and, to be safe, most practices, as a policy, do not designate NPPs as supervisory personnel over diagnostic tests. In many instances, it is not necessary because the required supervision is only level one or general, which does not require the physician’s presence in the office suite. However, in instances where a NPP is the ordering practitioner of a diagnostic test, such as an EKG, the test may still be billed ‘incident to’ the NPP even though the NPP is not the supervisor of the test. Also, if it is within the state scope of practice for the NPP to perform diagnostic tests, they may do so without physician supervision and direct bill Medicare for these, although payment will only be at 85{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}.

Where there appears to be a conflict with CMS ‘incident to’ supervision levels, the supervision requirements override the ‘incident to’ requirements.

Note also, that there are separate rules for certain vaccine shots. For example, an RN administering flu vaccine shots does not require supervision. This comes under specific directives and the supervision guidelines don’t apply.

James B. Calnan, CPA, is partner-in-charge of the Health Care Services Division of Meyers Brothers Kalicka, P.C., Longmeadow. Certified Public Accountants and Business Consultants; (413) 567-6101.