Order compliance equals payment for outpatient radiologists

2001 11 16 10 13 24 706

This article begins a monthly series of billing-related articles for U.S.-based radiology practitioners, courtesy of Coding Strategies Inc. If you'd like to offer your comments or suggestions about the material, please e-mail [email protected].

By Melody W. Mulaik
Coding Strategies Incorporated

2001 11 16 10 13 24 706Ensuring that an order is present to justify radiology services performed is a key issue for U.S. practices that serve nonhospital patients.

On September 27, 2001, the Centers for Medicare and Medicaid Services (CMS) released Transmittal 1725. This memorandum provides additional clarification regarding the ordering of diagnostic tests. According to the CMS, an "order" is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary.

The order may conditionally request an additional diagnostic test, if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician (for example, if a diagnostic mammogram is positive, performing an ultrasound if clinically indicated). An order may include the following forms of communication:

  • A written document signed by the treating physician, which is hand-delivered, mailed, or faxed to the testing facility

  • A telephone call by the treating physician or their office to the testing facility; and

  • An e-mail by the treating physician or their office to the testing facility

If the order is communicated via telephone, both the treating physician or their office, as well as the testing facility, must document the telephone call in their respective copies of the beneficiary’s medical records.

Section 15021 revisions

The Medicare Carriers Manual (MCM), Section 15021, was recently revised to clarify concerns for radiology-specific compliance with changing, or adding to, treating physician/practitioner diagnostic test orders.

The treating physician/practitioner must order all diagnostic tests furnished to a beneficiary who is not an institutional inpatient or outpatient. A testing facility that furnishes a diagnostic test ordered by the treating physician/practitioner may not change the diagnostic test or perform an additional diagnostic test without a new order. This policy is intended to prevent the practice of some testing facilities to routinely apply protocols that require performance of sequential tests.

When the radiologist at a testing facility determines that an ordered diagnostic radiology test is clinically inappropriate or suboptimal, and that a different diagnostic test should be performed (for example, an MR should be performed instead of a CT scan because of the clinical indication), the radiologist or testing facility may not perform the unordered test until a new order from the treating physician/practitioner has been received.

Similarly, if the result of an ordered diagnostic test is normal and the radiologist believes that another diagnostic test should be performed (such as a renal sonogram that was normal, and based on the clinical information, the radiologist believes an MR will reveal the diagnosis), an order from the treating physician must be received prior to performing the unordered diagnostic test.

If the testing facility cannot reach the treating physician/practitioner to change the order or obtain a new order and document this in the medical record, then the testing facility may furnish the additional diagnostic test if all of the following criteria apply:

  • The testing center performs the diagnostic test ordered by the treating physician/practitioner.

  • The radiologist at the testing facility determines and documents that, because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary.

  • Delaying the performance of an additional diagnostic test would have an adverse effect on the care of the beneficiary.

  • The result of the test is communicated to and is used by the treating physician/practitioner in the treatment of the beneficiary.

  • The radiologist at the testing facility documents in their report why additional testing was done. For example: (a) the last slice of an abdominal CT scan with contrast shows a mass requiring a pelvic CT scan to further delineate the mass; (b) a bone scan reveals a lesion on the femur requiring plain films to make a diagnosis.

This radiologist exception applies to a radiologist of a testing facility who furnishes a diagnostic test to a beneficiary who is not a hospital inpatient or outpatient. The radiologist must document accordingly in his or her report to the treating physician/practitioner.

Test design

Unless specified in the order, the radiologist may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test. These could include the number of radiographic views obtained, the thickness of tomographic sections acquired, or the use or non-use of contrast media.

Clear error

The radiologist may modify, without notifying the treating physician/practitioner, an order with clear and obvious errors that would be apparent to a reasonable layperson, such as the patient receiving the test (for example, an x-ray of the wrong foot was ordered).

Patient condition

The radiologist may cancel, without notifying the treating physician/practitioner, an order because the beneficiary’s physical condition at the time of diagnostic testing will not permit performance of the test (e.g., a barium enema cannot be performed because of residual stool in colon on scout KUB; PA/LAT of the chest cannot be performed because patient is unable to stand). When an ordered diagnostic test is canceled, any medically necessary preliminary or scout testing performed is payable.

The information contained in the program memorandum is helpful in clarifying Medicare expectations for radiology-specific compliance concerns. The next article in our series will focus on the new ICD-9 U.S. guidelines for radiology, and their expected impact on practices across the U.S.

By Melody Mulaik
AuntMinnie.com contributing writer
November 19, 2001

Melody Mulaik is president of Coding Strategies Inc.

Copyright © 2001 Coding Strategies Incorporated

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