The Centers for Medicare & Medicaid Services has three levels of supervision for testing services: general supervision, direct supervision, and personal supervision. Non-Medicare payers typically only recognize direct supervision, where a physician of the practice is on-site and available. Certain ophthalmic tests do not have a designated level of supervision since they are routinely performed by a physician.

When tests do have designated levels of supervision, a physician can direct clinical teams to perform ordered ophthalmic testing. This is referred to as delegated services. Delegated services require the presence of a physician order in the medical record.

A physician order should indicate:

• Specific test(s) and site (e.g., right, left or both eyes)
• When the test is to occur (current date or in the future)
• Chart note clearly reflecting the medical necessity of the test

Insurance payers require that all medical records include a compliant physician signature. Unsigned physician orders delegating the test do not support the intent and will not be considered appropriate for payment upon payer review.

When a test that can be delegated is performed by the physician, the chart documentation should clearly reflect this so an outside reviewer will not be looking for an order.

The Code of Federal Regulations (42CFR Section 410.32) states that diagnostic tests may only be ordered by a treating physician. Tests that are not ordered by the physician who treats the beneficiary are not reasonable and necessary.