For exams with and without contrast should a physician be present? How is that documented?
The Medicare supervision level for contrast exams such as CT and MR is direct supervision. In the office that means the doctor has to be in the office suite, but not necessarily in the room. The hospital definition is different in that the physician doesn’t even have to be on campus. The policy for the supervision of diagnostic tests is in section 20.4.4 of the Benefits Policy Manual. This is what it says about direct supervision: “For services furnished in CY 2011 and following, which require direct supervision, the supervisory practitioner may be present in locations such as physician offices that are close to the hospital or provider-based department of a hospital where the services are being furnished but are not located in actual hospital space, as long as the supervisory physician remains immediately available. Similarly, as of 2011 for services requiring direct supervision, the supervisory practitioner may be present in a location in or near an off-campus hospital building that houses multiple hospital provider-based departments where the services are being furnished as long as the supervisory physician is immediately available.” Records for the day need to show which physician was supervising exams.