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By Melody Mulaik

Non-physician practitioners (NPPs), such as physician assistants (PAs) and nurse practitioners (NPs) may be able to perform and bill for services independent of a physician. However, radiology practitioner assistants (RPAs)/registered radiology assistants (RRAs), who are frequently referred to as physician extenders, require physician supervision at all times. These individuals play a valuable clinical role in many organizations, but it is important to ensure that you are billing compliantly for their services.

The Centers for Medicare and Medicaid Services (CMS) requirements for supervision of diagnostic tests are found in the Medicare Benefit Policy Manual, Chapter 15, Section 80. There are 3 levels of supervision: general, direct and personal. All interventional procedures are not classified as diagnostic tests so they are listed as “concept does not apply.” This means that the procedure should be billed under the provider who is authorized to perform the procedure. By current American Medical Association (AMA) and CMS guidelines this is limited to physicians and NPPs previously designated above.

Historically, diagnostic procedures performed by RPA/RRAs that require personal physician supervision were covered only if the physician was in the room with the extender throughout the procedure. This now varies depending on state law and scope of practice regulations.

The supervision guidelines listed in the Medicare Benefit Policy Manual apply to all sites of services and are not limited to physician offices and independent diagnostic testing facilities (IDTFs). CMS clarified in the 2009 and 2010 Final Rules for the Medicare Outpatient Prospective Payment System (OPPS) that diagnostic and therapeutic services performed in a hospital outpatient department must be provided under physician supervision, and the required level of supervision for a diagnostic test is that which is indicated in the Medicare Physician Fee Schedule (MPFS). This guideline applies to outpatient departments within the hospital as well as remote departments.

Even with the recent changes, CMS guidelines and state scope of practice statutes may not permit a health care professional to perform all services for which he or she has been trained. For example, many RPA/RRAs receive training to perform procedures that are listed by Medicare as requiring personal supervision. Because of Medicare’s supervision rules, RPA/RRAs are not allowed to perform and bill for these studies unless a supervising radiologist is in the room during the performance of the entire procedure. The changes apply only to diagnostic tests.

There are multiple considerations including, but not limited to, state scope of practice, payer requirements and supervision considerations. It is important not to confuse supervision guidelines with billing requirements. The bottom line is that no physician may bill Medicare separately for diagnostic tests performed in a hospital outpatient setting by a radiologist extender unless an exception applies. Either the NP/PA is a credentialed individual that bills under their own provider number, the RPA/RRA is allowed to perform designated procedures under direct supervision or there is no claim generated for the professional component.

Melody W. Mulaik, MSHS, CRA, RCC, RCC-IR, CPC, COC, FAHRA, is the president of Revenue Cycle and Coding Strategies Inc.

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