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APP Supervision and Diagnostic Tests: Clarification from CMS

If your medical practice offers imaging services, a recent clarification from the Centers for Medicare & Medicaid Services (CMS) requires attention. The March 16 2023 memo entitled: “Supervision Requirements for Diagnostic Tests: Manual Update” outlines the circumstances for which advanced practice providers (APPs) may provide diagnostic tests. Specifically, CMS states:

“When NPs, CNSs, and PAs personally perform diagnostic tests … the supervision/collaboration requirements … don’t apply. Rather, these practitioners are authorized to personally perform diagnostic tests under the supervision/collaboration requirements applicable to their practitioner benefit category pursuant to state scope of practice laws and under the applicable state requirements.” [Accordingly], “diagnostic tests can’t be billed to Medicare as incident to services.”

The topic isn’t a novel one; indeed, CMS expanded the supervision requirements in 2021. At the time, however, stakeholders were left confused by the language of the rulemaking. The 2021 Final Rule stated that a physician may offer general supervision of diagnostic tests, with no mention of nurse practitioners, certified nurse specialists, or physician assistants. Further, the tests that require personal supervision dictate that a physician must be in attendance, according to the then-published text.

Although it took two years, the recent memo provides clarity to the supervision requirements. Advanced practice providers may supervise diagnostic tests. CMS edited the language in the Medicare Benefit Policy Manual to read:

“Direct Supervision - in the office setting means the physician (or other supervising practitioner) must be present in the office suite and immediately available to furnish assistance and direction…”

This new language was accompanied by additional clarifications and can be reviewed at this link.

To determine the application of this newly clarified rule for your practice, the supervision requirements for the imaging test(s) being performed must be understood. The manufacturer of the equipment may be a resource; however, the rules change, and it’s better to go directly to the source of the regulations – the federal government. To query CMS’ requirements, look up the CPT code under the Physician Fee Schedule.

There is a column titled “Phys Supv” that reveals the level of required supervision. (See this manual for instructions about the tool, as well as descriptions of the supervision levels. Note that this guide has not yet been updated with the newly released requirements, as of the time of the publication of this article.)

The clarification from CMS is welcome as it helps sift through the once muddy water. Despite the changes in federal rulemaking, however, remember that APPs must act within their scope of practice under state licensing laws. Therefore, state regulations must be reviewed (and followed) as well.

If you have questions about this recent clarification, or other practice management issues, please contact SVMIC's Medical Practice Services department at 800.342.2239 or

About The Author

Elizabeth Woodcock is the founder and principal of Woodcock & Associates. She has focused on medical practice operations and revenue cycle management for more than 25 years. She has led educational sessions for a multitude of national professional associations and specialty societies, and consulted for clients as diverse as a solo orthopaedic surgeon in rural Georgia to the Mayo Clinic. She is author or co-author of 17 best-selling practice management books, to include Mastering Patient Flow and The Physician Billing Process: Avoiding Potholes in the Road to Getting Paid. Elizabeth is a Fellow in the American College of Medical Practice Executives and a Certified Professional Coder. In addition to a Bachelor of Arts from Duke University, she completed a Master of Business Administration in healthcare management from The Wharton School of Business of the University of Pennsylvania. She is currently a doctoral student at the Bloomberg School of Public Health of Johns Hopkins University.

The contents of The Sentinel are intended for educational/informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and/or change over time.

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