Orthopaedic surgeons and their billing staff typically pay careful attention to Medicare’s incident-to-billing rules. But they often aren’t as well informed on Medicare’s rules for supervision of diagnostic testing.

Some practices confuse the two sets of rules, despite the differences between them. This article focuses on supervision of diagnostic imaging most commonly done in orthopaedic practices.

Medicare designates a level of supervision for each type of diagnostic test; the three levels used are general supervision, direct supervision, and personal supervision, as shown in Table 1. The Medicare fee schedule assigns a supervision level to each diagnostic Current Procedural Terminology (CPT) code. (These designations do not appear in Code-X.) The Medicare Web site (http://cms.hhs.gov) has additional information and clarification. Tables 2 through 4 list the codes that apply to imaging services. Additional, very specific supervision codes also apply to physical therapy services.

General supervision
The general supervision classification specifies that the following conditions must be met:

• The procedure is furnished under the physician’s overall direction and control in the office setting.
• The physician’s presence is not required during the performance of the procedure.
• The physician is responsible for ensuring that the nonphysician personnel who actually perform the diagnostic procedure are trained and are responsible for ensuring the maintenance of the necessary equipment and supplies to perform the tests.

For example, a patient comes into the office while the physician is at the hospital and a technician takes a radiograph for the physician to review and read later. As shown in Table 2, the supervision requirement applies to the technical component of the X-ray, and the physician can bill for the global diagnostic service because he or she was available by phone.

Direct supervision
The direct supervision classification specifies that the following conditions must be met:

• A physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure in the office setting.
• The physician does not have to be present in the room when the procedure is performed.

For an example of how this classification would be applied, consider the following scenario, which is depicted in Table 3:

Physician A is out of the office. A partner, Physician B, is in the office when one of Physician A’s patients comes in for magnetic resonance imaging (MRI). Physician B’s name must appear on the claim form—not Physician A’s—and the technical component should reflect Physician B as the supervising physician. In this example, the MRI is sent to a radiologist to be read.

Some practices make a mistake in coding because they code by the practice’s income distribution plan instead of by the rules. The fact that this was Physician A’s patient doesn’t matter because Physician A was not present to supervise this diagnostic test.

The impact of the direct supervision requirement can also be seen when Physician A is out of the office and Physician B is in surgery, leaving only the physician assistant in the office. The MRI should not be taken for the Medicare patient because there isn’t a physician in the office to supervise.

Personal Supervision
Codes that are marked for personal supervision require that a physician be in attendance in the room during the performance of the procedure, as depicted in Table 4. As a practical matter, most orthopaedic practices will schedule services that have a personal supervision requirement in a hospital setting. Circumstances can occur, however, in which such diagnostic imaging is done in an office. In these cases, the physician must be in the room and should probably do the procedure rather than watch the technician.

Nonphysician providers may not supervise diagnostic tests that require physician supervision. Nonphysician providers—including physician assistants, nurse practitioners, and clinical nurse specialists—are not defined as physicians and may not act as supervisory physicians.

Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates.