There are three core requirements for a radiology test to be covered under Medicare. The test must be properly ordered by a treating physician (with limited exceptions), the test must be performed by an authorized supplier, and the test must be performed under the proper level of physician supervision.
Full Answer
What level of supervision is required to provide radiology services?
Radiology services must be provided under at least a general level physician supervision. Additionally, certain tests must be provided under direct or personal supervision, which require higher levels of physician presence and involvement.
What are the requirements for coverage of radiology services?
The last of the major requirements for coverage of radiology services is the level of physician supervision that is required given the specific test being performed. Radiology services must be provided under at least a general level physician supervision.
Does CMS require physician supervision of radiation therapy?
Physician supervision of radiation therapy services in free standing therapy centers also require the direct supervision, but CMS notes in its guidance that this supervision must be performed by a physician excluding non-physician practitioners.
Does Medicare cover radiology services?
The Centers for Medicare & Medicaid Services (CMS) is considering a change in the carrier’s manual for Medicare that is aimed directly at radiology. Each freestanding provider of radiology services will be required to determine whether it is a freestanding physician’s office or an Independent Diagnostic Testing Facility (IDTF).
What is direct supervision in radiology?
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.
What is general supervision for Medicare?
“General supervision” means the definition specified at 42 Code of Federal (CFR) 410.32(b)(3)(i), that is, the procedure or service is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure.
Which level of supervision requires the physician's physical presence in the room while the services are rendered?
Personal SupervisionCMS identifies three levels of supervision to be provided depending on the complexity and risk associated with the performance of a particular clinical service or procedure: “Personal Supervision”: The physician is present in the room when the service is being performed.
What is professional component of radiological services?
Most radiology services or procedures, although described by a single CPT code, comprise two distinct portions: a professional component and a technical component. The professional component is provided by the physician, and may include supervision, interpretation, and a written report.
What is the difference between direct and indirect supervision?
Direct: the supervisor is working directly with the trainee, or can be present within seconds of being called. Indirect: the supervisor is either: Local: on the same geographical site, is immediately available for advice, and is able to be with the trainee within 10 minutes of being called.
What does general supervision mean?
General Supervision: The supervisor provides continuing or individual assignments by indicating generally what is to be done, limitations, quality and quantity expected, deadlines and priorities. Additional, specific instructions are given for new, difficult, or unusual assignments.
What are the three levels of supervision?
For most of these services, three levels of physician supervision are applicable: general, direct, and personal (42 CFR 410.32).
What does radiological supervision and interpretation mean?
Radiologic supervision and interpretation (S&I) codes are used to describe the personal supervision of the performance of the radiologic portion of a procedure by one or more physicians and the interpretation of the findings.
What does concurrent supervision mean?
Concurrent Supervision means the periodic reviews to be carried out by FISDL and consisting of spot checks to the Training Activities to ensure that these take place in the designated locations and that the attendance records accurately reflect the presence of the PATI Participants, all in accordance with the terms of ...
What is the difference between professional and technical components in radiology?
The technical component of a charge addresses the use of equipment, facilities, non-physician medical staff, supplies, etc. Technical charges do not include the physician's professional fees, but include the use of all other services associated with the visit.
Can a radiologist bill for an office visit?
A patient's visit with the IR prior to a procedure can variously be considered a consultation, an office visit, or a non-billable component part of the procedure depending on the circumstances.
What does TC modifier mean?
Technical ComponentModifier TC is defined as “Technical Component” and should be appended to a procedure code when the provider rendered only the technical component of the service.
What are the levels of physician supervision?
The Medicare rules for the physician supervision of diagnostic tests state that there are certain levels of physician supervision necessary in IDTFs and physicians’ offices. These levels are categorized as general supervision, direct supervision, and personal supervision. General supervision means that ...
What is general supervision?
General supervision means that the physician is not necessarily on-site. The services of the facility are provided under his or her supervision and control, however, and the physician is responsible for the calibration of the equipment, the training of the technologists, and overall operations.
What is CMS program memo?
A CMS Program Memorandum has mandat ed that all carriers perform site visits verifying that each IDTF application is located at the stated address, that the equipment listed on the application is available on the premises, and that diagnostic tests are being performed by appropriately licensed/certified personnel.
How are hospitals regulated?
Hospitals are regulated through the Joint Commission on Accreditation of Healthcare Organizations and through the conditions of participation imposed by the Medicare program. Likewise, mammography services are excepted from the supervision rules because mammography is regulated by the US Food and Drug Administration.
Can a radiology group reassign benefits?
A radiology group cannot reassign group benefits; only individual physicians can do so.
Does a physician's office have to bill payors?
A physician’s office must also bill payors directly for at least 70% of the diagnostic tests performed by the entity; an IDTF may have a higher percentage of interpretations performed by another service bills payors directly.
Do hospitals have accreditation?
Hospitals have accreditation and participation oversight, and physicians’ offices are certified through state licensure, with certain clinical safeguards being in place due to that mechanism’s existence. The independent physiological laboratories, however, functioned without any kind of regulatory oversight.
What is the supervision requirement for radiology?
Thus, the supervision requirement is a significant compliance issue for medical practices who must establish and maintain appropriate policies and procedures regarding supervision of various levels of radiology diagnostic tests. Each level of supervision has very specific requirements that must be met.
What are the requirements for radiology?
The last of the major requirements for coverage of radiology services is the level of physician supervision that is required given the specific test being performed. Radiology services must be provided under at least a general level physician supervision. Additionally, certain tests must be provided under direct or personal supervision, which require higher levels of physician presence and involvement. Failure to provide the appropriate level of physician supervision and to document the supervision in the chart will result in loss of coverage under Medicare and Medicaid. Any claims submitted in spite of not meeting the supervision requirements will be considered to be not reasonable or necessary by Centers for Medicare & Medicaid.
What is a non-hospital setting for a radiology test?
The rules are different depending upon whether the provider is located in a hospital or in a non-hospital setting such as an independent diagnostic testing facility or physician’s office. Generally, in a non-hospital setting, a diagnostic radiology test must be ordered by the treating physician. The treating physician rule is located in ...
What is the responsibility of a physician for a diagnostic test?
The physician is also responsible for maintaining the necessary equipment and supplies for the safe operation of the diagnostic test. Direct and personal supervision each require higher levels of physician involvement and generally require some level of physician presence throughout the performance of the test.
What is the highest level of physician supervision?
The highest level of physician supervision is personal supervision. Personal supervision requires a physician to actually be present in the room during the performance of the procedure. Personal supervision generally involves diagnostic tests with invasive or otherwise dangerous aspects.
What happens if you fail to provide a physician's supervision?
Failure to provide the appropriate level of physician supervision and to document the supervision in the chart will result in loss of coverage under Medicare and Medicaid.
Can an intervening physician cancel a diagnostic test?
In cases where there is a clear and obvious error in the initial order, the interpreting physician may make appropriate modifications. The intervening physician may also cancel orders based upon the patient’s medical condition at the time of the diagnostic tests.
Who must pay for TC of radiology services?
A/B MACs (B) must pay under the fee schedule for the TC of radiology services furnished to beneficiaries who are not patients of any hospital, and who receive services in a physician’s office, a freestanding imaging or radiation oncology center, or other setting that is not part of a hospital.
What is the CPT code for nuclear medicine?
The TC RVUs for nuclear medicine procedures (CPT codes 78XXX for diagnostic nuclear medicine, and codes 79XXX for therapeutic nuclear medicine) do not include the radionuclide used in connection with the procedure. These substances are separately billed under codes A4641 and A4642 for diagnostic procedures, and code 79900 for therapeutic procedures and are paid on a “By Report” basis depending on the substance used. In addition, CPT code 79900 is separately payable in connection with certain clinical brachytherapy procedures. (See §70.4 for brachytherapy procedures).
What is the CPT code for FDG PET?
Effective for claims with dates of service on or after April 3, 2009, contractors shall accept FDG PET claims billed to inform initial treatment strategy with the following CPT codes AND modifier PI: 78608, 78811, 78812, 78813, 78814, 78815, 78816.
What is the ICd 9 code for PET scan?
In order to pay claims for PET scans on behalf of beneficiaries participating in a CMS-approved clinical trial, A/B MACs (A) require providers to submit claims with, if ICD-9-CM is applicable, ICD-9 code V70.7; if ICD-10-CM is applicable, ICD-10 code Z00.6 in the primary/secondary diagnosis position using the ASC X12 837 institutional claim format or on Form CMS-1450, with the appropriate principal diagnosis code and an appropriate CPT code from section 60.3.1. Effective for PET scan claims for dates of service on or after January 28, 2005, through December 31, 2007, A/B MACs (A) shall accept claims with the QR, QV, or QA modifier on other than inpatient claims. Effective for services on or after January 1, 2008, through June 10, 2013, modifier Q0 replaced the-QR and QA modifier, modifier Q1 replaced the QV modifier. Modifier Q0/Q1 is no longer required for services performed on or after June 11, 2013.
How is Medicare payment based on locality?
The payment locality is determined based on the location where a specific service code was furnished. For purposes of determining the appropriate payment locality, CMS requires that the address, including the ZIP code for each service code be included on the claim form in order to determine the appropriate payment locality. The location in which the service code was furnished is entered on the ASC X12 837 professional claim format or in Item 32 on the paper claim Form CMS 1500. Global Service Code
How much iodine is in a low osmolar contrast material?
Supply of low osmolar contrast material (100-199 mgs of iodine); Supply of low osmolar contrast material (200-299 mgs of iodine); or Supply of low osmolar contrast material (300-399 mgs of iodine).
What is the SNF code for contrast material?
When a radiology procedure is provided with contrast material, a SNF should bill using the CPT-4 code that indicates “with” contrast material. If the coding does not distinguish between “with” and “without” contrast material, the SNF should use the available code.
What is direct supervision in radiation therapy?
In the hospital outpatient setting, direct supervision means that the physician or non-physician practitioner must be immediately available to furnish assistance and direction throughout ...
Is incident to services covered by Medicare?
As defined by the Social Security Act , “services… furnished as an incident to a physician’s professional service, of kinds which are commonly furnished in physicians’ offices and are commonly either rendered without charge or included in the physicians’ bills” are covered under Medicare.
Do you need to be under supervision for X-rays?
With very few exceptions, diagnostic X-ray and other diagnostic tests payable under the physician fee schedule must be furnished under at least a general level of physician supervision and some require direct or personal supervision. More information regarding the supervision of diagnostic tests can be found here.
What is the definition of physician supervision?
The Physician Supervision of Diagnostic Procedures indicator specifies a level of physician supervision required for certain diagnostic tests. The levels of supervision are "general," "direct," and "personal" supervision, and each of these levels of supervision have a corresponding indicator value assigned to each diagnostic procedure.
How many hours of DSMT training is required?
CMS is clarifying DSMT policy to specify that all 10 hours of the initial DSMT training and the two (2) hours of annual follow-up DSMT training may be furnished via telehealth in cases when injection training is not applicable.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
This article is a list of diagnostic services that may be performed in an Independent Diagnostic Testing Facilities (IDTF) provided they have the appropriate physician supervision and technician requirements. The CPT codes in this document do not imply coverage of the procedure.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
How long is a Medicare read?
Read time: 6 minutes (1192 words) Until recently, strict Medicare rules allowed only fully licensed physicians to take responsibility for the supervision of diagnostic tests. The Centers for Medicare and Medicaid Services (CMS) this year revised these long-standing rules, handing an expansion of purview to non-physician practitioners.
What is the interim rule for a physician assistant?
The interim rule released in 2020 allowed for the first time, during the public health emergency, nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs), and certified nurse-midwives (CNMs) – collectively referred to by CMS as non-physician practitioners (NPPs) – to supervise diagnostic tests. The interim rule change applied to tests performed in physician offices, hospital outpatient departments, and provider-based facilities. Only in the independent diagnostic testing facility setting were these NPPs still barred from supervising diagnostic tests.
What does level 3 mean for a test?
Also, seemingly contradicting the rule change to permit all tests to be supervised by NPPs, CMS stated that Level 3 tests requiring personal supervision means a physician must be in attendance in the room throughout the performance of the test.
Is a diagnostic imaging test reimbursable under Medicare?
Failure to provide the appropriate level of supervision for a diagnostic test can render the service not “reasonable and necessary” and, therefore, not reimbursable under Medicare rules. More concerning, failure to provide for diagnostic test supervision consistent with Medicare’s requirements has resulted in fraud and abuse allegations by the government that claims submitted by various providers for such testing services were false claims. Those investigations often have led to substantial monetary settlements and corporate integrity agreements with the government that often accompany such settlements.
Will CMS extend the relaxed requirements?
These reforms created considerable anticipation in the diagnostic imaging industry that CMS would extend the relaxed requirements when it created new permanent rules. As anticipated, CMS made such changes in its 2021 rules, but whether they fully accomplished these reforms is an open question.
What is the definition of physician supervision?
Background: The Physician Supervision of Diagnostic Procedures indicator specifies a level of physician supervision required for certain diagnostic tests. The levels of supervision are "general," "direct," and "personal" supervision, and each of these levels of supervision have a corresponding indicator value assigned to each diagnostic procedure.
What is Medicare Administrative Contractor?
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.
Who is the pre implementation contact for the HHS?
Pre-Implementation Contact(s): Gail Addis, 410-786-4522 or [email protected], Patrick Sartini, 410 786-6952 or [email protected] (For information on the revision of the definition of the physician supervision of diagnostic services.), Kathleen Kersell, 410-786-2033 or [email protected].
Does the revision date apply to red italicized material?
Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.
Supervision Levels
- The Medicare rules for the physician supervision of diagnostic tests state that there are certain levels of physician supervision necessary in IDTFs and physicians’ offices. These levels are categorized as general supervision, direct supervision, and personal supervision. General supervision means that the physician is not necessarily on-site. The services of the facility are provided under his or her supervision and control, however, and the physician is re…
Practice Categories
- It should be noted that these levels of supervision pertain only to freestanding sites. Hospitals are regulated through the Joint Commission on Accreditation of Healthcare Organizations and through the conditions of participation imposed by the Medicare program. Likewise, mammography services are excepted from the supervision rules because mammography is regulated by the US Food and Drug Administration. The rules do ap…
Compliance Requirements
- Some radiology practices will no longer be considered physicians’ offices. As IDTFs, they must have one or more supervising physicians who are responsible for the direct, ongoing oversight of quality, the proper operation and calibration of equipment, and the qualifications of nonphysician personnel. The designated supervising physician must show p...
Carrier Site Visits
- A CMS Program Memorandum has mandated that all carriers perform site visits verifying that each IDTF application is located at the stated address, that the equipment listed on the application is available on the premises, and that diagnostic tests are being performed by appropriately licensed/certified personnel. The site visit is also intended to verify the presence of a supervisory physician for tests requiring direct or personal super…
Maintaining Productivity
- Several of the supervision requirements can be expected to undermine the efficiency of radiologists. There are, however, some options available to enhance productivity. Physicians who need to be physically present in the office or IDTF because of supervision requirements may be able to interpret additional films from off-site locations if they have support from a picture archiving and communications system (PACS) and teleradiology eq…
Conclusion
- A freestanding facility, in the Medicare world, can only be one of three things: a physician’s office (which may be a clinic), an ambulatory surgical center, or an IDTF. The CMS criteria defining a physician’s office are so strict because, in CMS’s opinion, a facility that does not meet those criteria does not have sufficient clinical supervision in the absence of additional regulation. CMS does try to make its decisions promote a high quality of care for th…