Must physicians directly oversee echoes?

ACC: No changes to Medicare supervision rules

How much physician supervision is required when running diagnostic tests such as echocardiography and caths? What about stress tests?

For a service to be deemed reasonable and necessary, according to the Health Care Financ-ing Administration (HCFA) - and thus covered by Medicare - a certain level of supervision is required.

Definitions are changing

Follow existing policies for now. But as part of the 1998 Medicare fee schedule, originally meant to take effect Jan. 1, HCFA published new definitions of supervision as a condition of payment:

General supervision applies to services furnished under the physician's overall direction; his or her presence during the test is not required. Examples: X-rays and EKGs.

Direct supervision requires the physician to be "present . . . and immediately available to furnish assistance and direction throughout the performance of the procedure." Examples: echocardiography and nuclear cardiology procedures.

Personal supervision requires the physician to be in attendance. Examples: all cardiovascular stress tests and cardiac catheterization.

Because of confusion surrounding HCFA's policy, the dust has not yet settled. As of Jan. 28, HCFA announced a delay in implementation of the new rules. The rules apply only to the technical components of tests for which Medicare Part B is billed. They do not apply to tests performed in the hospital, any paid under Part A, or to the professional components of the tests.

ACC doesn't agree

HCFA notes that the teaching physician's presence is required during a stress test when overseeing the work of a resident. The agency points to the separate CPT code for the supervision of stress tests as evidence of importance.

The American College of Cardiology (ACC) in Bethesda, MD, submitted to HCFA its objections concerning the supervision requirements. The ACC particularly opposes the classification of echocardiography and nuclear cardiology procedures as requiring direct supervision. In addition, appropriate supervision for stress tests is the most sensitive of the issues. Until the group's annual scientific session in late March in Atlanta, there was lack of consensus concerning the appropriate level of supervision for stress testing.

At that meeting, the executive committee decided to request coding changes to reflect the optimal level of supervision.

"A stress test is not a stress test is not a stress test," explains George Silberman, a member of the ACC's Health Policy staff. "Ideally the policy would allow physician discretion."

Given the range of populations on whom diagnostic stress tests are performed, the best policy is one where clinical judgment is used to determine the most appropriate level of supervision. Where direct supervision is appropriate for some testing, personal supervision may be necessary for others.

In response to recommendations from the radiology community, HCFA moved ultrasound, including echocardiography, from general to direct supervision. The agency rejected the ACC's arguments that direct supervision is not required for nuclear cardiology procedures. Also, HCFA moved magnetic resonance imaging (MRIs) and computed tomography (CT) procedures done without the introduction of contrast media from the direct to the general category. Other MRIs and CTs remain in the direct category.

HCFA states unequivocally that a physician cannot provide direct or personal supervision via telemedicine.