A change in physician supervision requirements in the proposed 2019 Medicare Physician Fee Schedule regulation would shift outpatient diagnostic tests performed by radiology assistants (RAs) from personal supervision to direct supervision, assuming it’s allowed by state law and hospital policy. If finalized, RAs, who are recognized in 28 states, can perform the diagnostic imaging procedure, including upper GIs and swallow function studies, as long as a physician is immediately available to take over if necessary. That’s a departure from personal supervision, which requires the physician to be in the room for these procedures.

The proposed change, which will probably be finalized because there’s little pushback, would be the only Medicare revision to supervision of diagnostic radiology in many years, said Melody Mulaik, president of Coding Strategies. Even though the rules for supervising and ordering diagnostic services are stable, auditors often find noncompliance in these areas, she said at an Aug. 29 webinar sponsored by the Health Care Compliance Association. But if it’s finalized, the change from personal to direct supervision of outpatient procedures performed by RAs will reduce incorrect operational and billing practices in some organizations, she said. Errors in supervision have led to a surge in self-disclosures, Mulaik added.

Supervision is built around the technical component of radiology and applies to hospital outpatient services, physician offices and in “under arrangements” between hospitals and other entities. According to the Medicare Benefit Policy Manual, there are three levels of supervision:

• General: Physicians don’t have to be onsite, but procedures are performed under their general direction and control. They include plain X-rays, some types of ultrasounds, CTs and MRIs without contrast, and some nuclear medicine exams, Mulaik said.

• Direct supervision: Physicians don’t have to be in the room when procedures are performed, but they must be immediately available and able to be interrupted. The manual states that “supervisory responsibility is more than the capacity to respond to an emergency, and includes the ability to take over performance of a procedure and, as appropriate to the supervisory physician and the patient, to change a procedure or the course of care for a particular patient.” Procedures that require direct supervision include MRIs and CT scans with contrast and IV pyelograms.

• Personal supervision: Physicians must be in the room where the procedures are performed. Mulaik said radiologists typically do the procedures themselves, including radiographic arthrograms and GI diagnostic procedures.