Know Your Role as Supervising Physician

The term "supervising physician" sounds generic, but to CMS, it's anything but. It's packed with rules and responsibilities - far more for a radiologist might know without expert help.

"It comes down to a physician having direct control of patient care, patient safety and quality," said Timothy Myers, MD, radiologist and president at Peacefield Radiology in the Minneapolis area.

From CMS's perspective it refers to the roles and responsibilities that the overseeing physician has at an independent diagnostic testing facility (IDTF), outpatient and inpatient hospital settings

Myers said that as a supervising physician, you have to be licensed in that state where the facility is located. Moreover, you must have participated in, understand and have direct knowledge of what the company is doing, from the standpoint of quality assurance and oversight of healthcare workers like technologists and nurses.

"You have to review them, do oversights, and have policies and procedures that guide the medical operations of the company. That's the main thing," said Myers, who consults with other radiology groups on practice management.

In addition to developing the protocols for procedures and studies, including when a physician should be contacted if there are emergent findings, the supervising physician is responsible for overseeing calibration and testing of the equipment so it achieves a certain quality, said Edward Neyman, MD, chief of radiology at Advanced Global Imaging in Chicago.

The government looks at a medical corporation in two ways: the business component and the medical component, said Myers. "The medical component of that corporation has to be in the hands of a physician," he said, to ensure that business folks aren't telling the physicians how to provide medical care. He likened this to the supervising physician role, which also helps separate the business and medical roles. "If we were to hire someone, I would write the professional description of what they would do, and would be responsible for their activities in patient care. But I would not advise them in the business function of filling out time cards, for example. As supervising physician, you're providing the physician oversight for the medical components of the company."

A physician can only have a supervising role at up to three IDTFs, said Myers. "There are requirements that limit that number to a small amount," he said, to make sure the physician has the ability to be hands-on and knowledgeable about the facility's operations.

Types of supervision

There are three types of supervision, said Neyman: general, direct and personal.

General supervision requires that the physician verify that the technology is working properly and that the protocols are developed and followed, Neyman said.

Myers added that general supervision basically means that the imaging is done under the physician's overall control and direction, but the physician is not required to be there. "As part of my supervising physician role for a portable X-ray or obstetrical ultrasound, I don't have to be in the room when it's done, but the technologist is under my overall supervision. I've set up the requirements, and there are specifics they have to follow." He likens it to the "captain of the ship" theory, where the captain doesn't need to be present, but the crew should know what's expected of them. If the ship sinks, it's the captain's fault. "If that person under my control does something wrong, it's my fault," he said.

With direct supervision, said Myers, the supervising physician has to be in the facility and immediately available, but not necessarily in the room. This is the case where the technologist is qualified to administer some types of contrast. "If we're just doing CTs at our center, I don't have to be in the building," he added, but with contrast administration, he does.

Myers said that the third level is personal supervision, where he needs to be in the room. This might be if a nurse practitioner or physician assistant is performing certain procedures or if newly hired employee is undergoing a qualification review.

These supervision designations can affect billing, for CMS at least. "What Blue Cross thinks and what CMS thinks can be different," Myers said. "If I'm not in the room, Blue Cross may not care." As for other insurers having separate rules, Myers said that he thinks they just follow CMS.

Myers said that for the most part, the rules make sense. "If you begin with the end in mind," he said, "the end being that you're ensuring patient safety and quality. You don't want an intern who doesn't know anything reading a report without supervision. You have to run it through the common sense mill."

Billing, coding and academics

From a billing and coding perspective, there are additional rules. Neyman explained that for each CPT code, there are certain types of physicians allowed to supervise in order to bill. For an X-ray, it would be a radiologist, for an echocardiogram, a cardiologist. Some studies can have several different specialists as supervising doctors, like with an ultrasound. "Usually Medicare has rules on what training and board certification is required," Neyman said. "Medicare defines who has the expertise."

For supervising physicians outside of IDTFs, the rules can be different. Myers explained that for attending doctors at academic institutions, the roles for overseeing interns, residents and fellows are a different ball game. Attendings have to review all the images and discuss the findings with the training doctors, then attest that they've personally reviewed the images. "That ensures the same thing as in the IDTF, that a licensed physician with understanding is directly overseeing, and ensuring the quality of medical care," he said.

What if you break the rules?

If the rules aren't followed properly, CMS has several punishments: financial penalties and possible jail time.

If CMS determines that the site is not properly supervised, they will mainly go after the facility, said Neyman. If CPT codes were inappropriately billed, that could be considered Medicare fraud and they could revoke the site and physician's ability to participate in Medicare.

Myers added that CMS can also require payback of past Medicare funds, and still require the facility to take Medicare patients, without payment expectation. "If it ruins the university, the hospital, they don't care. You broke the rules," he said.

If CMS finds a pattern of abuse and thinks the physician knowingly disregarded the rules, CMS can allege fraud and send the doctor to jail. Myers added that this is uncommon, but jailing a physician is a good deterrent for future infractions.

That's the regulatory side. Neyman said that if the lack of proper supervision injured a patient, the patient can sue.

Where to get information?

With strict rules to follow, where does a supervising physician get the proper advice? Myers said that if working for a company, they will most assuredly have someone in charge of compliance to go through the guidelines with you. "Medicare sets out the guidelines and requirements, and that person is responsible for knowing the compliance issues," he said.

It's important to also read the 855b Medicare application form when filling it out as a supervising physician, said Neyman, adding that it shows what you're responsible for. "Most people," he said, "just look at the form, read it, understand it and sign it."