In a transmittal issued last week, the Centers for Medicare & Medicaid Services (CMS) extended newly-revised supervision rules for certain diagnostic tests paid via the Medicare Physician Fee Schedule (MPFS) to services paid under the Outpatient Prospective Payment System (OPPS) for hospital outpatient departments. The transmittal relates to services performed by a registered radiologist assistant who is certified and registered by the American Registry of Radiologic Technologists, or a radiology practitioner assistant who is certified by the Certification Board for Radiology Practitioner Assistants (RAs/RPAs).

Effective January 1, 2019, diagnostic tests paid under the MPFS that would otherwise require a “personal” level of supervision (Level 3, in the room throughout the procedure), may be furnished under a “direct” level of physician supervision to the extent permitted by state law and state scope of practice regulations for tests performed by RAs/RPAs. This policy was included in the final MPFS rule for calendar year (CY) 2019, which we summarized here.  There are currently 28 states that are reported to have such statutes or regulations relating to RAs/RPAs. CMS has followed up with additional guidance applying the new supervision requirements to tests performed by RA/RPAs for Medicare hospital outpatients. Transmittal 251 (Change Request 11043), dated November 30, 2018, updates the Medicare Benefit Policy Manual to provide that the technical component of all tests, except for Medicare inpatients, that must be performed under the personal (in the room) supervision of a physician, may be performed under direct physician supervision (defined below) if those services are performed by RAs/RPAs who are authorized to perform the test under state law.  Similar to the newly-revised supervision rules for diagnostic tests paid under the MPFS, the application of this new requirement to Medicare hospital outpatients becomes effective January 1, 2019.

The meaning of “direct supervision” differs in the MPFS and OPPS rules. For testing services performed for Medicare beneficiaries in physician offices and IDTFs under the MPFS, “direct supervision” is defined to mean that the supervising physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of that test. For tests performed for Medicare hospital outpatients in an on-campus or off-campus outpatient department of the hospital under the OPPS, “direct supervision” means that the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure. The OPPS does not impose a proximity requirement so long as the supervising physician can be immediately available to furnish assistance and direction.

It should be noted that the MPFS Final Rule – now also applicable to Medicare hospital outpatients – only impacts the supervision requirements associated with an RA’s/RPA’s performance of diagnostic tests.  It does not allow an RA/RPA to perform radiology interventional/surgical procedures or otherwise modify existing restrictions on an RA’s/RPA’s scope of services.  Additionally, even if state law permits RAs/RPAs to perform various non-test radiology procedures, the new Medicare rule is limited to the scope of physician supervision of diagnostic tests.

Although the new rules relax the standard for physician supervision of tests when an RA/RPA performs certain diagnostic tests, unchanged are CMS rules that state that only fully licensed physicians may supervise tests.  RAs/RPAs may perform a diagnostic test if permitted within their state scope of licensure, but they may not supervise technologists who perform diagnostic tests.  Such supervision must be performed by a physician.