Discover the Perfect Doctor Billing Format for Supervision

Doctor billing format for Supervision

chapter of H ofma and welcome to another of our Tennessee trains on Tuesdays uh before I introduce our speaker this morning um I do have a few housekeeping items that I would I like to make you aware of um remember that spring Institute is next week and you can still register online at thespring institute.org um the Gloria Adams Golf tournament is Monday May 19th at the Vanderbilt Legends Club in Franklin and there's more information also at dpring institute.org golf uh if you have CPE requirements uh to receive a continuing education certificate you must be connected to the webinar for at least 90% of the total time respond to at least three of the four polling questions you do not need to get these right but you do have to respond and more d details can be found in the policy section of our website at tnh hf.org so this morning we're very um pleased to have Paul Kim with us Paul is um Paul is a principal in the health Law Group at obber klor who represents Health Care Providers and manufacturers and Paul advises clients in all aspects of health law from corporate compliance counseling to reimbursement litigation he's worked in uh reimbursement uh Arena Fraud and Abuse privacy clinical research issues from the patient provider payer and government perspectives and he has a unique understanding of healthcare industry and an in-depth knowledge of the issues and challenges today's clients are facing um and without further Ado I will U turn it over to Paul Kim thank you thank you Valerie uh good morning and uh good afternoon um today we'll be uh discussing uh physician supervision um when I worked at the central office of CMS um center for Medicare Medicare Services here in Baltimore Maryland uh physician supervision was not only um not only imposed for purposes of determining medical necessity um but also uh to to uh ensure quality of care um and today um we will go we will uh go through the variety of services as well as certain types of providers and suppliers where physician supervision is imposed uh by CMS okay so let's talk about the levels of supervision that CMS has defined uh first and probably the least stringent level is General physician supervision what that requires is that the physician provide overall direction and control um The Physician need not be physically present in the office or with the patient or with whomever um uh that he or she is supervising a nurse a physician assistant uh Etc um The Physician however does need to provide overall Personnel training as well uh especially when it uh involves um certain medical equipment or devices and supplies uh and to the extent equipment is involved The Physician is also required to um provide uh overall maintenance of such medical equipment um so these are the elements of what CMS expects to see uh when CMS has established and imposed General physician supervision level for particular Services uh or particular uh providers uh clearly the main issue for most of us in the audience um is the fact that the supervising physician is not required to be actually even in the office and May in fact be outside the office and available by cell or pager the next level physician supervision is direct supervision as simple as these terms may appear to we will discuss further later but um this has caused tremendous confusion uh quite frankly since Medicare was established back in 1965 uh but basically direct supervision does require physical presence of the physician but in the quote unquote office suite okay again very simple terms but we will discuss further later um the variety of situations that meet uh potentially an office suite furthermore the supervising physician must be immediately available very simple terms nevertheless um variety of questions and factual scenarios that actually may comply uh and and constitute immediate availability now in some of the older claim forms and maybe even some of the existing claim forms uh for for non-medicare um payers you may see direct personal supervision well CMS tried to uh clean this up as much as possible but bottom line whenever you see that term either in a manual po provision or regulation or claim form really what the pay is meaning is direct supervision okay so again physical presence in the office suite whatever that may be and the physician must be immediately available whatever that may be now at the other end of the spectrum and probably the most stringent is personal physician supervision here CMS expects the physician to be in the room with the patient or with the nurse or technician or other clinical staff whom he or she is supervising so you can see that at one end General supervision fairly easy to understand because from a physical presence point of view the doctor does not even need to be in the office and then at the other end here personal supervision also fairly easy to understand because the physician must be in the room with the patient or the the uh clinical staff that he or she is supervising so what's in the middle is what has caused so much confusion so let's let's break it down um but before we continue in in in terms of um direct supervision I want to take this opportunity right now to just um get a sense of the audience and ask the first polling question Valerie okay let's get this polling question launched here has your organization ever experienced a denial of a claim for inadequate physician supervision and please choose one okay we have about 96% so I'm going to go ahead and close that one and I'll share these results looks like um 54% say it doesn't apply to them 35% say I don't know and 12% say yes okay thank you very much um so I'll try to make this nevertheless interesting for those of you um where this issue is not applicable or um um hasn't experienced this I mean I guess bottom line is in terms of phys supervision even though that may appear to be a scope of practice issue a licensing issue many insurance companies including the federal insurance company the Medicare program and really that what they are an insurance company have used physician supervision as means of auditing and as means of requesting uh fund a return of the funds a refund of the funds recruitments so hopefully that Financial aspect has sped some additional interest at this point now uh but before we start returning any monies or arguing about any monies that are owed to the government or other thirdparty payers um let's talk further about Direct supervision uh again this has caused uh most conf the most amount of confusion in terms of physician supervision and has been the subject of the the most amount of government audits investigations and litigation okay as I mentioned earlier direct supervision really has two components first is office suite all right what is that well think about your own uh physician um whom you visited recently all right you go in there's a reception area and couple of uh patient rooms maybe even a smaller waiting room before you meet the doctor those are all typically considered office suite okay however um you know there are uh different types of office suite and some practices may have offices on different uh floors uh floor one floor three for example um other offices might be separated so that sweet a might be part of the doctor's office sweet B may be a um maybe an IT company Sweet C may be a CPA firm and then sweet d as in David is the other part of The Physician Office uh all on the same floor well clearly you can see the tremendous amount of uh permutations of facts um and therefore the central office of CMS deliberately uh did not Define office suite further but instead deferred to local Medicare contractors that process and pay claims to determine whether or not a particular provider's uh factual scenario meets the definition of office suite um typically you may have different buildings on a campus uh you may have different floors in the same building and as I mentioned of different offices on the same floor um typically however most of the Medicare contractors have been okay as long as the offices are on the same building okay it's a very general statement but that appears to be the most outer boundary that the contractors would um approve even if the building next door is physically closer than the top floor and the first floor okay even though physically geographically closer generally the Medicare contractors have been focused on the same building um likewise when it comes to immediately available again a variety of permutations of facts um there are certain aspects of availability however the most obvious one is physical distance Geographic distance hence the linkage and the use of the term office suite but also from a practical perspective I think there's what I coined as audio distance you know if in a in a real life situation if a nurse is tending to a patient and the nurse needs assistance he or she may yell for help and as long as a supervising physician can hear that isn't that immediately available able doesn't that constitute immediate availability furthermore even if the supervising physician is right next door in the next office if the supervising physician is also with the patient uh and maybe involved in some deep conversation about their history and physical whatever um you know what I coin as mental distance or preoccupation uh doesn't that also raise questions about whether the person is immediately available or is that enough that the person is right next door so again depending on the factual scenarios the Medicare contractors have deferred I'm sorry the central office of CMS has deferred to the Medicare contractors to determine not only whether those facts represent an office suite but also whether those facts of a particular provider or supplier represent uh immediate availability um you know you we will discuss further later but sometimes um there are situations where CMS has specified the maximum number of services or Personnel that a supervising physician can supervise however in most of the services and for most of the providers that is not specified but but that issue however need not necessarily be um you know uh inqu you don't need to inquire that uh with the local contractor necessarily however to the extent that it may raise issues about immedate availability that's when um it may be um right for uh an inquiry and and and and and hopefully you'll receive a response generally from my personal experience as well as um experience of other clients despite the potential delay the Medicare contractors have been generally responsive uh in answering questions about whether or not certain um sit circumstances meet meet an office suite or meet uh immediate availability now one issue that I do want to note uh at this point is when it comes to a supervising physician there actually is a a a case from Hawaii where uh a an oncologist who was working at the uh infusion center uh was documented and um um logged in as a supervising position but because of contractual disputes the oncologist uh pursued a whistleblower lawsuit the government intervene and um argue that immediate that uh direct supervision did not exist uh in part in main part because that oncologist did not even know he was the supervising physician so how could he possibly render the requisite level of direct supervision well uh I think to the surprise of many folks both legal and clinical the court dismissed the lawsuit dismissed the false claims act whistleblower case in in part holding that the physician the supervising physician does not actually need to be aware that he or she is the supervising physician and that the only two requirements are that one the supervising physician is in the office and two that the supervising physician is immediately available so very surprising uh to many uh but um very um poed in terms of whether or not um preoccupation uh or other issues of immediate availability may be a bar uh to actually being immediately available now before we continue with the next issue um I also want to take time again to ask the second polling polling question uh Valerie please thank you okay any one second here Martha I may need your assistance here I can't seem to get it to progress to the next following question oh I'm sorry I've got it has your organization ever contacted CMS or a Medicare contractor to ask a question related to physician supervision okay we have about 86% voting I'm going to close this and share the results and we have 8% answering yes 12% no 32% I don't know and 48% does doesn't apply to me okay okay thank you so hopefully those of you who did um actually pose an inquiry whether anonymously or not uh did receive the answer uh that actually addressed the question even if it wasn't the the the the good answer that you were looking for but regardless um I'm glad to hear that uh the uh many folks have actually pursued that route um because again it actually is available and despite the potential delay uh is one of the best ways to protect yourself from subsequent audits because you have that inquiry in hand um uh demonstrating that you've you've asked the government contractor about this and the government contractor responded and you relied on that response okay now um you know obviously before you actually do make that inquiry um you should also uh conduct your own research and due diligence to try to see whether there are particular answers that uh do apply to you uh because I know most folks um um would rather not contact the government U if not necessary and so I want to now talk about the variety of sources that are available uh so that you can obtain answers about physician supervision levels so that you can comply with them so you can avoid Audits and investigations now the um there are a variety of sources um of course there's the Social Security Act which is the Medicare law but quite frankly it's very Broad and uh and some somewhat vague in many cases uh uh because it's statute um and even though it may give Authority for CMS to implement those uh statutory Provisions um not many times will you actually see particular Congressional language you know mandating certain levels of physician supervision um so what you see most of the time is the federal code of regulations that the that CMS actually issues to implement uh the um uh particular statutory provision so for example if Congress um included a provision in the Federal in the C act to provide diagnostic testing to Medicare beneficiaries well that language alone would authorize CMS to now draft and promate regulations that detail how the medic program would render would furnish diagnostic services to Medicare patients so regulation is one of the primary sources of of information unfortunately it's not um exhaustive in other words you won't necessarily find physan supervision um in the regulations clearly the three levels of physician supervision that I just described they are actually uh cited in the regul tion but when you go through different types of services and different types of providers and suppliers that regulation regarding pH physician supervision is not necessarily referenced nevertheless when you go down further in the chain of or hierarchy of guidance materials Source materials you'll see that the Medicare program does indeed require certain levels of supervision so that you can't just stop at regulations is is is my primary Point here next level also equally binding are National coverage determinations these are um basically medical policies that CMS issues at a national level to determine whether a certain service or certain Health Care item may be covered and under what conditions under what type of uh clinical criteria uh would Medicare cover and pay for those Services um in addition although not uniform and not always consistent you may see some local contractors issue their own local coverage determinations uh they may be in essence verbatim as the national coverage determination but not always um and they may have additional nuances added on now most of the time unlike the ncds the LCDs tend to be uh a better resource for identifying physician supervision levels so in other words the NC might not specify but when you look at the LCD of your local Mac um if one is available you may see some physici supervision levels being imposed as a requirement um as a condition of of payment in addition there are National Medicare manuals uh discussing coverage claims processing benefits program integrity and so forth so you may find certain um types of uh physician super provision levels being imposed in the manuals instead even though the regulations are silent even though the coverage determinations are silent so that's an additional Source where you need to be mindful to double check so that you can make sure you're you're being compliant and of course uh there is the uh Medicare physician fee schedule um this is uh an annual regulation of CMS um that Divi the division that uh issues this annual rag is B basically where I worked uh at the when I worked at the central office here in Baltimore and we would um issue regulations but also work the databases to make sure that certain Services were paid uh appropriately um uh but you'll see in that fee SC fee schedule database and this is not the fee schedule that's published in the Federal Register along with the regulations but you have to go onto the CMS website um and pull up the databases you'll see that on one of the columns is the is a column for position supervision and for each part each uh Service uh particular service denoted by a CPT code you'll see whether or not CMS has imposed a a particular level of physician supervision and if so what that may be and CMS also has a Legend um um and it may be to find so I presented it here uh in the next slide but for example for a particular CPT code when you go to that column in the database under physician supervision you may see a number one in that and and you'll see from this slide that means that that particular service requires General supervision okay now there may be some other types of services where um if if it's performed by certain types of non-physician practitioners CMS won't is not imposing any physician supervision at all okay and you'll see those codes there as well typically that column has been used to denote different levels of physician supervision uh for diagnostic tests okay not always but typically uh you'll see codes next to diagnostic test um and you'll see from the rest of the uh the legend so to speak um most of these Services even if it involves um non-physicians or Physicians they really are describing diagnostic services and therefore um most of the physician supervision level codes that are included in the fee schedule physician fee schedule database um really are just describing uh those levels required of diagnostic services now um before I dive into the particular services and providers that require physician supervision and what level that may be I would like to take this time to ask my next polling question thank you Valerie okay what is your organization's primary source for information regarding physician supervision e okay we have about 82% I'll leave it open a few more seconds if anyone else would like to vote or poll okay going close that and the results it looks like um most of us are using transmittal or bulletins from CMS or Medicare contractors at 46% 38% attorney your consultant 8% trade associations 4% commercial Publications and 4% of us like to read the Federal Register wow Federal Register those are hardcore healthc care personnel and uh I'd be happy to talk to those 38% that working with attorneys and Consultants um anyway I'm glad that you're familiar with these different Publications because they do a very good job of summarizing um uh the particular uh Source materials that I just mentioned before um I'm sorry I'm having issues with the slides I hope everyone can see them Valerie can you still see the slid um it's it's partial on my screen it's like it's slowly coming across the screen okay it might be the connection uh one second please e Valerie can you see the slides now no Paul unfortunately I can't okay all right I apologize everybody I don't I don't know what's going on that's it okay yes thank you all right sorry I'm trying to move to side where we were but it's just not one second okay good so um let's go down the list of particular services and providers where CMS policy and regulations require physician supervision um the first policy uh or first benefit is called incident two uh essentially incident two uh uh acts works like this you go see a physici The Physician provides a service to you and then tells you to see a nurse or a technician for additional Services even though the physician did not provide directly that uh subsequent Service as long as the requirements of incident 2 are met the physician May bill for that particular service using the physician's name on the claim as if the physician directly rendered that subsequent service to you okay and one of the requirements of incident two is physician supervision and here direct supervision is what's required um this has been around since 1965 but again because of the vagueness the deliberate vagueness of the definition of direct supervision is caused tremendous um confusion but is probably the um one of the top reasons why uh healthc care providers uh are subject to investigations and audits uh by the government um interestingly enough even though radiation therapy is listed separately in the statute uh ch chemotherapy is not and so therefore the reason why Medicare covers chemotherapy is because it falls under the definition of an incident to service okay uh likewise infusion centers um um of uh are paid under Medicare because there's an incident to service and must meet uh the levels of supervision the requirements of physician requirements of incident 2 including the physician uh uh Direct supervision by a physician uh cardiac rehab is another benefit uh that falls under an incident two service and so therefore must meet the requirements of incident 2 and uh must also have direct physician supervision now Medicare was trying to be pragmatic and so that they issued couple of exceptions for example if a patient is homebound is unable to uh leave the home maybe even bedridden alog together but nevertheless needs Services um Medicare is does not require the physician to always render all of the services in the patient's residence uh but rather may have a nurse for example go visit the service go visit the patient to render the service uh without the physician and and so and yet that service of the nurse may be billable as an incident to service even though so there was no supervising physician in the patient's home at all okay so to to accommodate those types of chronically ill patients uh even under the incident to uh requirements uh CMS has alleviated and Exempted uh those Services uh from the direct physician supervision requirement often times um Physicians actually work in the nursing home uh but CMS did not give them a break at all and in fact even though nursing home is not is considered a patient's home um CMS has distinguished that and nevertheless in order for incident two services to be met the requirements to be met requires that the physician actually uh be in the p in in the office of the nursing home the four walls of the nursing home in order for incident two services to be met in other words when Physicians have offices in a nursing home um the direct supervision is met only if the physician is in the four walls of his or her office and then sees the patient in that office rather than traveling you know throughout the nursing home seeing patients bedside in the patients rooms okay so there uh perhaps because of the potential proximity uh CMS did not exempt those services and nevertheless still requires uh direct Supervision in the four walls of the office of the physician diagnostic services as mentioned uh a couple times before is another category of services that require physician supervision and depending on the test there are variety of levels of physician supervision that CMS has imposed again for many of these tests you can find out what level is required by uh reviewing the uh physician fee schedule database um C uh try to be pragmatic here as well and if indeed certain non physician practitioners render the service for example a Medicare um nurse practitioner or Medicare physician assistant if it's those folks rather than a registered nurse or medical assistant or somebody else who is not able to enroll directly in Medicare but rather uh certain non-physician practicians who are enrolled and who can enroll directly to Medicare when these tests are performed by them no physician supervision is required okay so CMS did make that made that exemption to accommodate really current Medical Practice furthermore especially in the LCDs okay the local coverage determinations you'll see that Medicare policies require certain qualifications of the supervising physician this isn't true for many other services they just want to see a physician okay but for certain types of diagnostic tests uh the local Medicare contractors have issued LCDs uh further specifying what type of qualification that supervising physician must have for example a cardiologist for a cardiac test um a radiologist for certain types of Imaging tests so you you want you'll want to note that and make sure that you review your local uh contractors local coverage policies uh uh to make sure that you're fully compliant when performing those diagnostic tests and speaking of diagnostic tests um there's actually a separate enrollment category called idtf uh and again CMS promega regulations regarding this this is purely a creature of Medicare to enable nonphysicians nonhospital uh providers to furnish diagnostic services Okay so literally you and I can own an idtf and as long as we meet the requirements uh to have our Center enrolled as an IDF for example have a supervising physician on staff and have all certified technicians on staff and so forth um we can actually render uh furnish diagnostic services build Medicare and collect reimbursement even though we're not part of a hospital even though I'm not a physician okay but the diagnostic services are in essence the same although limited than a general Physician Office um so you have to note from your local coverage determinations what types of tests uh an idtf in that jurisdiction can actually furnish okay similar to all diagnostic services The Physician supervision level varies with the particular test an idtf can be fixed or mobile now you might think that that makes it easier but no if you have a mobile IDF for example a mobile ultrasound provider or a portable x-ray supplier for example that they're not an idtf they're actually separate either way if you if you have a portable device medical equipment in your van and you go to nursing homes or you go to physician offices and that particular test requires more than General supervision like direct or personal that means you need to have inside that van those so to speak four panels of the van a supervising physician who can render the requisite level of director personal supervision okay so having a mobile IDF is not necessarily easier as opposed to having a fixed um freestanding center now unlike a physician office however because an IDF is not owned by physicians or not required to be anyway and not owned by or affiliated with a hospital the particular technicians that actually perform the test must meet all applicable State qualification certification registration and other requirements okay that's a major difference those same individuals working in a physician office are not subject to that why because it's a physician office but here because this is a non-physician non-hospital location those individuals those technicians performing those tests must meet all those applicable qualification requirements and an idtf here is an example where CMS has actually set in a regulation the maximum number uh a physician can supervise and it's three so a one particular supervising physician May supervise up to three idfs okay it doesn't say that once you're in an idtf you're limited to three tests but especially when idfs are performing General supervision tests then that means a supervising physician in his or her office May technically be listed as the general supervisor for three of to three idfs portable extra supplier it's actually different from an IDF even though it smells taste looks the same they're actually separately listed in the Medicare law and have separate uh an additional uh and different requirements but all of the services uh require General super Vision so that's why it looks the same in terms of physician supervision uh compared to an idtf okay um they are all inherently mobile so you may compare a portable x-ray supplier to a mobile idtf but a mobile idtf actually might be able to perform additional services that may be mobile whereas the port record supplier is limited in the in the in the type of services that it can render now just as a side you should note that portal we suppliers actually paid for the transportation however for whatever reason um neither Congress nor CMS has uh permitted payment for transportation for mobile idfs even though the vans that they drive look literally identical but again portable exess suppliers yes position supervision and yes it's only General radiation therapy as I mentioned earlier this is actually separately listed in the Medicare law with its own uh requirements um even though chemotherapy is not um but this is also one of the type of services where you can't find the supervision requirements in the statute in the regulation or even in the McD or LCD surprisingly you'll find the most clear articulation of the physician supervision level in the Medicare manuals instead okay and when you go through that you'll find that r ration therapy requires direct supervision okay now I want to make a note lot a lot of times because of the equipment involved radiation therapy is rendered in hospital settings as an outpatient service okay the direct supervision uh is applicable uh primarily to freestanding settings why because under Hospital Services even though physician supervision is required its definition and and implementation of direct physician supervision is much more relaxed okay why because cmf presumes and and uh uh expects uh physician uh presence and availability in hospital settings as opposed to a freestanding ambulatory setting okay but either way when you look through those Source material you'll find that in the manuals radiation therapy requires direct phys supervision a variety of non-physician practitioners May directly Lo in Medicare render Services uh and and receive reimbursement albe it at certain lower levels for example 85% for a nurse practitioner um but uh they have some level of physician supervision requirements as well okay of course for whatever they do uh CMS defers to State lure and scopal practice requirements why because even if CMS is silent on supervision levels if the state if state law requires certain level of physician supervision when uh a non-physician practitioner performs certain types of tests well you have to you have to meet that okay even if uh CMS is silent on that issue all right um typically direct supervision is not required of any of these mpps unless the physician wants to build for their services as an Institute service okay in other words even though state law doesn't require it if you the physician want to bill for your services of your physici assistant as an incident to service okay and and collect that 100% reimbursement level as opposed to the 85% that Pas receive from Medicare then you have to meet all of the requirements of incident two including direct supervision even though again state law may not require that of physician assistance Services okay uh also another example where CMS has imposed limits for crnas uh uh a a a supervising physician can only medically direct uh CRNA uh up to four crnas okay so there are certain certain circumstances where crnas may be working dependently uh especially if state law does not require certain levels of phys supervision however in other situations The Physician might be involved or medically direct that CRNA for that surgery and to the extent that CR that the physician is doing that uh in order to collect you know for example 50% uh of the reimbursement whereas and the CRNA would collect the other 50% of reimbursement rather than 100% um CMS is imposed a limit of four uh crnas to be supervised uh physician assistance typically every state law has some level supervision and it's typically General supervision okay so yes physician assistance uh does require General physician supervision um in contrast nurse practitioners they don't really have a physician supervision requirement but more but rather a collaboration requirement some states actually require that a physician and a nurse practitioner sign a collaboration agreement it may set forth um how they collaborate whether um you know a weekly uh telephone discussion um you know uh where the phys can be reached uh in an emergency whatever so that type of agreement if a state requires it details those um um elements um but to the extent a state does require some level of collaboration yes CMS does refer to that so um even though the Medicare policies might be silent when you're dealing with a nurse practitioner and his or her Services you need to make sure that state law is satisfied including those involving collaboration same with clinical nurse specialists um now after that these other types of practitioners nurse midwives psychologist social workers therapists audiologists uh typically there is no physician supervision required at all under state law and in fact CMS recognizes that and does not actually impose physician supervision levels either okay so um bottom line physician super supervision does become an issue for some of the nurse practi some of the non-physician practitioners but in in different ways and for some none at all okay medical residence you may think that they're involved primarily in hospital settings uh and so for supervision does not apply however in even in hospital settings um when a teaching physician is involved a teaching physician May Bill uh and collect uh professional reimbursement uh for their services reimbursement for their Professional Services as if the teaching physician rendered that service uh wholly uh in in in in total um the key the the the issue is that the teaching physician must identify uh the critical or key portion of a particular service so if there's a appendectomy the the surgeon teaching physician would identify what's the critical or key portion it must actually be in the o with the medical resident for the for that or those critical or key portions in order for the physician to Bild and receive 100% reimbursement for the Professional Services of that surgery okay now sometimes CMS um you know which is unusual in my point of view but CMS has actually set forth and dictated um you know the practice of medicine in in essence and requires phys presence throughout the entire procedure colinos be the prime example even though many teaching if not all teaching Physicians well I can identify certain parts of the colonoscopy where he or she needs to be present for um and his and probably historical reasons um CMS is requiring that the teaching physician be present for the entire procedure uh while a medical resident um is performing that service um so that's that's U one um exception um on the other side uh recognizing the need for um nonsurgical medical res residents to gain particular experience with patient interaction if the medical residents are working in primary care clinics or family health clinics um CMS does allow the Physicians to supervise up to four residents um and this means not in the office with the patient and the resident but outside the office but up to four residents and still allow that Physicians to build uh certain levels of low uh enm or evaluation man management visit codes as if the physician perform those visits him or herself okay so it's it's allowing residents to have this solar interaction with the patients uh meanwhile there is a supervising physician outside the office supervising of to four residents and being able to build and and receive reimbursement Hospital out patient Department um the policy regarding Hospital out department has morphed um numerous times quite frankly um they focus on the main building I'm sorry they focus on the provider base setting because it's the outermost uh physical location so in the main building they're not as concerned they're presuming physician presence and and and availability uh if it's in a building still on the campus they're still not that concerned because again they're presuming physician presence and availability now if they're off campus uh that's where they may see some concern but if they're off campus to a point where they have to actually meet provider base settings and that means that a free standing location is being treated for reimbursement purposes as if it was part of the main hospital okay so they're being paid at a hospital under the hospital reimbursement uh methodology rather than like a like a physician Clinic Under The Physician fee schedule okay so that outermost setting appears to be the primary concern for uh CMS but it's very different in terms of what CMS expects okay it really is in essence General supervision um um and and doesn't even require the physician to be actually in the office unless those particular Services require that uh direct level supervision where the physician must be in the office okay there's also some language in the manuals about qualification of the physician you don't see this very often in the manuals um other than in LCDs as I mentioned earlier involving diagnostic tests but CMS after several Renditions of this policy has now settled into all right um the the supervising physician for Hospital out services are as follows they do require that the physician have some capab ability um but not specifically being able to perform those Services um and nevertheless can still be the supervising position but in terms of availability it really is a general supervision other than those particular Services uh that require uh uh physical presence in the office suite now they do separate however between Diagnostic and therapeutic services okay for diagnostic services again through the supervising physician must be capable clinically able all right but doesn't necessar need mean that there's some historical experience with those particular Services um similar language in terms of direct supervision requiring immediate availability but as I stated does not mean actual physical presence in the office or even in the uh uh provider based location um now the only exception to this is if we're dealing with a nonhospital or uh entity okay many hospitals don't have all of the equipment necessary so they will contract with other uh providers um more than vendors but they're actual providers there for those providers to render those diagnostic services because it's a completely non-hospital setting not a provider based setting there CMS is imposing uh the same direct supervision um requirements as if the test was performed in a physician office office okay so the relationship of that location to the hospital is a is a dispositive factor in imposing that but outside of those factors if you're talking about Hospital settings you'll see that immediate availability uh does not require physical precence which is much more relaxed compared to freestanding locations now for therapeutic services or Hospital incident to um CMS went even further and is actually permitting nonphysician practitioners to be the supervising uh individual okay um again that individual must be clinically able um and but physical presence is not required now for therapeutic services incident 2 therapeutic services unlike for diagnostic services CMS has however listed certain services that only require General supervision which is even more relaxed than direct supervision um and those and that list is updated periodically uh but but but so so for those tests the person does not need to be even clinically able the person does not need to be immediately available the person does not need to be physically present it's General supervision the first slide that we discussed earlier today but any other services that are not listed uh there you're you're requiring CMS is requiring direct supervision which means you're required to have a physician or a non-physician practitioner who is clinically able immediately available but not necessarily physically present uh in the premises okay hi Paul it's Valerie I wanted to uh kind of give you a heads up we're just about out of time here so um we have one more polling question and I'm not sure how many other slides you have but just wanted to make you aware of the time thank you very much the polling question is at the end and I only have I think a couple of slides I appreciate that okay um just quick notes in terms of audit work um the common mistakes you'll see and that you want to watch out for is lack of documentation it's a it's a shame but I I'm sure it's this isn't new to you but um obviously um writing notes in the patient chart is most ideal but there are other ways to uh document physician presence um not having any uh physician presence uh or supervision is is obviously the the the most um egregious error and and would probably invite government scrutiny attention but also just understanding what level is required you may need to do General rather than I'm sorry you may need to perform direct supervision rather than General again checking for LCDs and to the extent that the ordering physician and the supervising physician might be different the claims must identify the actual supervising phys okay because especially if the ordering position was not even there to render the supervision so these are some of the common mistakes that you'll see and things that Medicare Auditors and and and government investigators look for so making sure you have internal pmps and Sops addressing physician supervision is the most ideal situation even if you make a mistake having those will help uh explain your issues away to the government uh again reviewing LCDs regularly uh keeping daily laws or using calendars to make sure you identify who's the supervisor practitioner is for that day uh for services that are that require phys supervision and then just double checking that the right practitioner is listed on the claims to ensure um accuracy so with that I would like to ask the final polling question please okay how many of the services discussed today does your organization furnish okay we have about 86% voting so I'm going to go ahead and close close that and we have 21% showing 1 to three 25% 4 to six all 4% and 50% doesn't apply great so so thank you I it sounds like i' I've identified and addressed um um if not all most of the services uh that you do are involved in so hopefully this uh topic about physician supervision has been helpful um uh again not just from a medical necessity and compliance purposes but also for audit purposes as well um I also apologize again for the technical diffic difficulty time it seems like every time there's a polling question my screen goes blank uh but um anyway U thank you for your patience and um I hope uh this has been helpful thank you so much Paul we appreciate it everyone have a good afternoon and