by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Feb 26th, 2015 - Reviewed/Updated May 8th
Be sure you know and understand the levels of supervision required so as not to result in non-compliance audits, possible fines, and take-backs. Supervision requirements may also affect your documentation requirements; document the presence during the procedure or performance if it requires personal supervision.
Find-A-Code has levels of supervision built into each code. To locate the level of supervision requirement in Find-A-Code, select the desired code and open:
ADDITIONAL INFORMATION tab to view PHYSICIANS SUPERVISIONS
For example, CPT code:
96101- Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic
Physician Supervisions: 9 - Concept does not apply.
Definitions: Levels of Supervision
General Supervision - means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, 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 - 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 the physician must be present in the room when the procedure is performed.
Personal Supervision - means a physician must be in attendance in the room during the performance of the procedure.
| Supervision Indicator | Explanation |
|---|---|
| 1 | Procedure must be performed under the general supervision of a physician. |
| 2 | Procedure must be performed under the direct supervision of a physician. |
| 3 | Procedure must be performed under the personal supervision of a physician. |
| 4 | Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist or a clinical psychologist or furnished under the general supervision of a clinical psychologist; otherwise must be performed under the general supervision of a physician. |
| 5 | Physician supervision policy does not apply when procedure is furnished by a qualified audiologist; otherwise must be performed under the general supervision of a physician. |
| 6 | Procedure must be performed by a physician or by a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical specialist and is permitted to provide the procedure under State law. |
| 6a | Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may supervise another PT but only the PT with ABPTS certification may bill. |
| 7a | Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may supervise another PT but only the PT with ABPTS certification may bill. |
| 9 | Concept does not apply. |
| 21 | Procedure must be performed by a technician with certification under general supervision of a physician; otherwise must be performed under direct supervision of a physician. |
| 22 | Procedure may be performed by a technician with on-line real-time contact with physician. |
| 66 | Procedure must be performed by a physician or by a PT with ABPTS certification and certification in this specific procedure. |
| 77 | Procedure must be performed by a PT with ABPTS certification or by a PT without certification under direct supervision of a physician, or by a technician with certification under general supervision of a physician. |
The definitions of supervision levels are also in the PUB-100 Internet Only Manual System, publication 100-02, Chapter 15, Section 80.
References/Resources
About Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Christine Woolstenhulme, CPC, QCC, CMCS, CMRS, is a Certified coder and Medical Biller currently employed with Find-A-Code. Bringing over 30 years of insight, business knowledge, and innovation to the healthcare industry. Establishing a successful Medical Billing Company from 1994 to 2015, during this time, Christine has had the opportunity to learn all aspects of revenue cycle management while working with independent practitioners and in clinic settings. Christine was a VAR for AltaPoint EHR software sales, along with management positions and medical practice consulting. Understanding the complete patient engagement cycle and developing efficient processes to coordinate teams ensuring best practice standards in healthcare. Working with payers on coding and interpreting ACA policies according to state benchmarks and insurance filings and implementing company procedures and policies to coordinate teams and payer benefits.
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