A good new year’s resolution is to ensure that all your current processes are compliant and reviewing orders is a great place to start. Understanding when and how diagnostic imaging services are ordered is critical to ensuring compliance and appropriate reimbursement. When discussing orders and their restrictions and requirements, Medicare services should be considered separately from non-Medicare. These two categories have very different requirements, and it is important to understand their differences and the associated operational and financial impact.
Most large commercial payers require preauthorization for high-cost studies such as CT, MRI or PET. It is the referring physician’s responsibility to obtain this prior approval by contacting the payer and providing the medical reason for the exam. If the facility and physician do not submit the exact code (or range of codes) that was approved, the claim will usually not be paid. If the incorrect exam was requested by the referring physician, no changes can be made without first contacting the referring physician’s office and obtaining a new preauthorization. Failure to do so could result in loss of reimbursement for both the facility and the physician.
At the present time, Medicare does not have a prior approval process like commercial payers. Instead, providers must determine whether the exam will be covered by reviewing the National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) and issuing Advance Beneficiary Notices (ABNs) as appropriate. In the non-hospital setting, Medicare pays for diagnostic tests, including imaging studies, only when the tests are ordered by the patient’s treating physician or nonphysician practitioner (NPP) and the treating physician/NPP is using the result in the management of the patient’s specific medical problem. The testing facility is not permitted to perform a different exam or an additional exam without obtaining a new order. However, this restriction does not apply to diagnostic tests furnished to hospital inpatients or outpatients.
Hospital diagnostic studies are governed by two separate provisions, and in those regulations, there is no statement restricting ordering authority to treating physicians. However, many Medicare contractors have taken the position that only treating physicians, even in hospitals, may order diagnostic X-ray tests. Providers should review their contractor’s published guidance. CMS has published specific rules for the ordering of diagnostic tests in the Medicare Benefit Policy Manual, Chapter 15, Section 80.6.
The treating physician/NPP may conditionally request an additional exam to be performed if the initial exam “yields to a certain value” determined by the treating physician/NPP (eg, perform breast ultrasound following mammogram, if clinical indicated). Conditional orders must be written for a specific patient. A treating physician/NPP cannot issue a blanket order.
CMS does allow three important exceptions to the ordering rules. The first relates to “test design,” which is the specific exam protocol –—for example, number of views, use or non-use of contrast, SPECT versus planar, etc. The second exception occurs when there is a clear and obvious error in the order “that would be apparent to a reasonable layperson.” The third exception involves the patient’s condition. If the patient’s physical condition will not allow the performance of the exam that was ordered, the radiologist may cancel the exam. For example, the treating physician orders a barium enema, but the initial scout film shows stool in the colon. In this situation the radiologist may cancel the barium enema without notifying the ordering physician. The imaging facility and the radiologist may bill for any medically necessary preliminary testing (like the scout film in the example).
Melody W. Mulaik, MSHS, CRA, RCC, RCC-IR, CPC, COC, FAHRA, is the president of Revenue Cycle and Coding Strategies Inc.