Outpatient Facility Coding Alert

Plus, know when and how the interpreting provider can self-order.

The rules surrounding how independent diagnostic testing facilities (IDTF) process order forms for diagnostic imaging services can be tricky. The guidelines aren't always clear-cut and can even vary depending on what type of procedure the physician orders.

Understanding the Centers for Medicare and Medicaid Services (CMS) guidelines on how coders and diagnostic imaging providers should handle diagnostic imaging orders is fundamental for any coder or office manager working in the specialty.

Consider these essential ground rules surrounding diagnostic imaging orders to keep your IDTF in compliance.

Defining an Order Form

First, it's crucial that coders and billers alike understand what does and does not constitute an order form. According to the Medicare Claims Processing Manual (Chapter 15, Section 80.6), an "order" is defined as:

• "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)."

Additionally, Medicare allows for practices to process an order through the following three means of communication:

• A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility; NOTE: No signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services;
• A telephone call by the treating physician/practitioner or his/her office to the testing facility; or
• An email from the treating physician/practitioner or his/her office to the testing facility.

Know these Rules Surrounding Order Changes, Reorders

Occasionally, a provider may conclude that a requesting physician's order for imaging will produce suboptimal or inconclusive results in respect to the patient's condition. In these instances, providers may not take it upon themselves to change the order. Instead, they must request an entirely new order from the ordering provider.

For example, if the interpreting physician believes that the ordering physician should have requested a magnetic resonance imaging (MRI) scan over a computed tomography (CT) scan, the interpreting provider does not have the authority to make a change without the ordering provider sending a new (or revised) order form.

"The same rules apply if the interpreting provider believes that additional testing needs to be performed in addition to the initial imaging ordered," says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. "In these circumstances, a new order needs to be sent in order for the interpreting physician to order any additional diagnostic testing," Rosenberg explains.

Caveat: There is one circumstance in which interpreting physicians may take it upon themselves to order additional testing. If a provider performs a screening mammography and detects an abnormality, the provider has the authority to order a diagnostic mammogram without underlying consent from the ordering provider of the screening mammogram.

Take these Steps when Ordering Provider is Unreachable

Imagine another scenario in which the testing facility cannot reach the treating physician to request a new or revised order. In these instances, Medicare states that the testing facility may perform additional diagnostic testing if the five 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.

Additional Rules for Changes to Diagnostic Testing

Finally, coders, office managers, and physicians need to know what additional changes the interpreting physician may make to a diagnostic imaging exam.

1. If the ordering physician does not specify number of views in the order, the physician may make changes to various "parameters" of the diagnostic test such as number of views (X-ray), thickness of tomographic sections acquired, and use or non-use of contrast.

2. The interpreting physician may modify an order with a clear or obvious error or inconsistency in respect to the patient's condition. For example, if the patient receives an order for a right foot X-ray despite trauma to the left foot, the interpreting physician may change the order.

3. The interpreting physician may cancel any diagnostictesting if the beneficiary's physical condition at the time of testing "will not permit performance of the test."

Note: These rules only apply to diagnostic testing on a beneficiary who is not a hospital inpatient or outpatient. Additionally, the interpreting physician does not need to notify the ordering provider that these three changes to the order form have been implemented.

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