Clarified in CMS Internet Only Manuals
The Centers for Medicare and Medicaid Services (CMS) issued Change Request 5743 on October 19, 2007 that incorporates language inadvertently omitted from Section 15021 of the Medicare Carriers Manual when the Internet Only Manual was published. This revision is being implemented on November 19, 2007 with an effective date of January 1, 2003.
Note: Unless specified, the sections are not applicable in a hospital setting.
Background:
In order that payment can be made for diagnostic tests, there are certain ordering requirements that must be met. The requirements for both ordering and following orders for diagnostic tests are specified in this change request which affects treating physicians and practitioners as well as the testing facility performing the tests.
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 for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:
· A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility;
· A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
· An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records.
Treating Physicians/Practitioners Ordering Diagnostic Tests
The treating physician/practitioner must order all diagnostic tests. For a test to be reasonable and necessary, it must be both ordered by the physician and the ordering physician must use the result in the management of the beneficiary's specific medical problem. A standing order is not sufficient to order clinical diagnostic laboratory tests payable under the Medicare Part B clinical laboratory fee schedule including orders for routine blood glucose monitoring. 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.
When a Different Diagnostic Test is Appropriate
When an interpreting physician 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 (e.g., an MRI should be performed instead of a CT scan because of the clinical indication), the interpreting physician/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 interpreting physician believes that another diagnostic test should be performed (e.g., a renal sonogram was normal and based on the clinical indication, the interpreting physician believes an MRI will reveal the diagnosis), an order from the treating physician must be received prior to performing the unordered diagnostic test.
Rules for Testing Facility to Furnish Additional Tests
If the testing facility cannot reach the treating physician/practitioner to change the order or obtain a new order and documents 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 interpreting physician 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 the 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; and
· The interpreting physician at the testing facility documents in his/her report why additional testing was done.
Example:
The last cut of an abdominal CT scan with contrast shows a mass requiring a pelvic CT scan to further delineate the mass.
Rules for Furnishing Different or Additional Tests
The following applies to an interpreting physician of a testing facility who furnishes a diagnostic test to a beneficiary who is not a hospital inpatient or outpatient. The interpreting physician must document accordingly in his/her report to the treating physician/practitioner.
Test Design
Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test (e.g., number of radiographic views obtained, thickness of tomographic sections acquired, use or non-use of contrast media).
Clear Error
The interpreting physician 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 (e.g., x-ray of wrong foot ordered).
Patient Condition
The interpreting physician 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). When an ordered diagnostic test is cancelled, any medically necessary preliminary or scout testing performed is payable.
Additional information and references can be found at:
http://www.cms.hhs.gov/transmittals/downloads/R79BP.pdf
