Economics
New Supervision Regulations Effective July 1, 2001
The Health Care Financing Administration (HCFA) recently published its new
supervision regulations, which will go into effect July 1, 2001. The new regulations will
only affect those diagnostic tests performed in the physician’s office or free-standing
setting [e.g. independent diagnostic testing facilities (IDTFs), multispecialty clinics].
Services provided in the hospital inpatient and outpatient settings should follow the
JCAHO accreditation standards and internal hospital policies. The ACR has submitted
several recommendations to HCFA on appropriate assignments of supervision levels for
radiology procedures. HCFA has accepted the ACR’s recommendations regarding
procedures related to contrast use, but has rejected the ACR position that ultrasound and
nuclear medicine procedures be categorized as direct supervision (with a few exceptions).
The ACR will submit comments to HCFA regarding our opposition to this decision and
further explain our position on supervision related to ultrasound and nuclear medicine
procedures.
The new supervision regulation continues to use the terms “general,” “direct” and
“personal” to identify levels of supervision. However, the definition for direct
supervision has been revised to eliminate confusion.
General supervision (level 1) is defined as “a procedure furnished under the physician’s
overall direction and control, but the physician’s presence is not required during the
performance of the procedure. Under the general supervision definition, the training of
the nonphysician personnel who actually perform the diagnostic procedure and the
maintenance of the necessary equipment and supplies are the continuing responsibility of
the physician.”
Direct supervision (level 2) is defined as “a physician 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 physicians must be present in the room when the
procedure is performed.”
Personal supervision (level 3) is defined as “a physician in attendance in the room
during the performance of the procedure.”
MRI and CT
HCFA has accepted the ACR’s recommendations to require MRI and CT procedures
performed with contrast to be performed under direct supervision. HCFA has also
accepted the ACR’s recommendations to require MRI and CT procedures performed
without contrast to be performed under general supervision. In addition, MRI procedures
are classified under the direct supervision level.
General Ultrasound
In response to the 1997 proposed supervision rules, the ACR submitted comments to
HCFA requesting that ultrasound procedures be categorized as direct supervision. The
ACR argued that ultrasound is a highly operator-dependent imaging method which
requires a radiologist’s availability to ensure quality examinations. The ACR commented
that a radiologist should be on-site or available to monitor and review the ultrasound
examination. The ACR argued that this enables the radiologist to be able to tailor the
examination to the specific clinical problem and review the study for completeness prior
to the patient leaving the office/hospital.
HCFA originally accepted these recommendations and published them in the October 31,
1997 final rule. Other medical groups argued that ultrasound should be categorized under
general supervision. Therefore after the barrage of comments from other medical
specialty groups, HCFA delayed the implementation of the supervision rule. HCFA has
now decided that most ultrasound procedures will be categorized under the general
supervision level with exception of ultrasound of the pregnant uterus (CPT codes 76805,
76810, and 76815). In addition, personal supervision will be required for
hysterosonography (CPT code 76831), ophthalmic ultrasound (CPT codes 76512 and
76513) and ultrasound guidance.
Cerebrovascular arterial, extremity arterial, extremity arterial venous, and spirometry
studies have been changed from direct supervision to general supervision. These are
specific to the non-invasive, duplex scan and doppler studies.
Transthoracic and doppler echocardiography have been changed from direct supervision
to general supervision. However, transesophageal echocardiography will now be
categorized as personal supervision, whereas the supervision rules did not apply in the
past. HCFA did not provide any details on how these decisions were taken.
Nuclear Medicine
The ACR has also requested that nuclear medicine procedures fall under direct
supervision, with a special request to allow teleradiology. However, as with decisions
HCFA made regarding ultrasound, the agency is also requiring general supervision for
nuclear medicine procedures.
The ACR will continue to monitor this issue. For the list of specific CPT codes and their
related supervision levels, please visit the Economics section of the ACR Web site or
contact the economics and health policy department at (800) 227-5463, ext. 4780.