Medicare Q & A
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Making sure that you provide appropriate orders for all diagnostic tests is a very important coding and compliance issue that causes problems for all radiology services. CMS (Centers for Medicare & Medicaid Services) has published numerous articles and transmittals on the requirements for proper ordering of diagnostic tests. Although the overwhelming liability is on radiology providers to obtain proper orders in accordance with Medicare, guidelines, it is a matter of time before the ordering provider also assumes liability for poor orders.
The following addresses frequently asked questions on this subject:
Q: At what point does the CMS consider an imaging order a "stale order"?
A: Hospitals or health systems may have a definition for stale orders at an enterprise level, which then applies to all types of services ordered within that hospital or health system. IDTFs or physician offices also should have a policy that addresses order validity. Payers that preauthorize or pre certify imaging studies often include an expiration date. However, unlike prescriptions for medication, there is not a standard expiration date for imaging orders.
If there is ever a question about the validity of an order received for imaging services, the referring physician indicated on the order should be contacted for verification.
Q: When can an imaging facility perform a different exam without obtaining an updated order from the treating physician?
A: For Medicare, if an order does not specify the exam protocol-for example, the number of views or whether contrast should be used-the radiologist may make this determination based on the patient's clinical indications without notifying the referring physician. This is usually referred to as a "test design" decision.
The radiologist also may change an order when it contains an error that would be obvious even to a layperson. For example, if the treating physician orders an X-ray of the left ankle to check the alignment of a patient's fracture, but it is the right ankle that is fractured, the facility can perform a right ankle X-ray without contacting the referring physician.
If the patient's condition will not permit the exam to be performed as ordered, the radiologist may cancel the exam without notifying the referring physician. Any medically necessary "scout" testing is payable.
There also is an exception to the ordering rules for situations when the radiologist determines that an additional exam is needed due to an abnormal result of the exam that the treating physician ordered but the treating physician is unavailable to provide an order. There are detailed requirements for providing and documenting the additional service (see Medicare Benefit Policy Manual, Chapter 15, Section 80.6.3).
Finally, the facility does not need a new or revised order to perform an exam that the treating physician conditionally ordered. For example, the physician orders a breast ultrasound after a diagnostic mammogram, if clinically indicated. You do not need an updated order if it is determined that the ultrasound exam is necessary.
If your system does not have the built-in capability for physicians to place conditional orders, updating your internal exam code to the conditionally requested study would not be considered an order change. If your computerized physician order entry system requires that you update the order to the conditionally requested study, you should verify that the original order with the conditionally requested study remains in the system.Part III will appear next week. About the Author Mr. Frosch is the President of Frosch Medical Consultants, Inc. in Plantation. Got a question for Ben? Click Ask Ben.