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Radiology Coding Alert

CMS Changes to Diagnostic-Ordering Rules Fall Short

Published on Thu Nov 01, 2001

The Centers for Medicare & Medicaid Services (CMS, formerly HCFA) announced much-anticipated modifications to the physician-ordering rule late in September. Although it provides for a number of specific exceptions, the rule reiterates CMS' position that radiologists may not change parameters of diagnostic tests or perform additional tests without a new order from the treating physician. While radiologists and professional coders see certain portions of the amended rule as a step in the right direction, most expressed disappointment that the rules remained as limiting as they did.
 
"I believe that most of us in the field had expected the ordering rules to be much less restrictive," says Thomas W. Greeson, a partner with Reed Smith, LLP in Falls Church, Va., whose client base is comprised of diagnostic-radiology groups, and formerly the general counsel for the American College of Radiology (ACR). "Radiologists are consulting physicians and are often the best qualified to determine the most appropriate diagnostic test to perform under the circumstances. The final result, however, does not provide the kind of flexibility most radiology practices would have liked."
 
Traditionally, radiologists have been frustrated because they were allowed virtually no latitude in adjusting or amending a referring physician's order when it was clinically indicated. Professional organizations like the ACR and the Radiology Business Management Association (RBMA), along with individual radiologists, have lobbied for more leeway in obtaining diagnostic images. CMS has studied the issue throughout 2001, and radiology professionals were optimistic about the potential outcome. "There are circumstances when a radiologist encounters a roadblock when executing the physician's order," Greeson says. "We hoped the changes from CMS would provide greater alternatives in those situations."

Test Changes Require New Order

The modified rules, communicated through CMS Transmittal 1725, affect only radiology offices and independent diagnostic testing facilities (IDTFs) and not those tests conducted with hospital inpatients, outpatients or emergency-department patients, Greeson says. CMS defers to hospital policy and Joint Commission standards for ordering diagnostic tests in the hospital setting. The new rules have been codified in Section 15021 of the Medicare Carriers Manual under the heading of Ordering Diagnostic Tests. The policy clearly states that the treating physician must request specific diagnostic tests from the radiologist via a written document, e-mail, or a telephone call (which must be documented in both the treating physician's and the radiologist's copy of the medical record).
 
The order may also conditionally request an additional diagnostic test, depending on the outcome of the original order. For instance, the treating physician's orders might request that the radiologist perform a transabdominal pelvic ultrasound (e.g., 76856, echography, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete), followed by a transvaginal sonogram (76830, echography, transvaginal) if medically indicated based on results of the transabdominal ultrasound. However, radiologists may not change parameters of diagnostic tests or perform additional tests without a new order from the treating physician. The transmittal notes that CMS' rationale for its position is "to prevent the practice of some testing facilities to routinely apply protocols which require performance of sequential tests."
 
CMS concedes that there are times when the radiologist, as a physician with substantial expertise in diagnostic study, may provide valuable input during the diagnostic process. For instance, the radiologist may identify when an MRI would produce better results than a CT, or recognize when a second modality should be used to follow up on a normal result from the original study. Nonetheless, the ordering-physician rules state that the radiologist cannot perform the unordered test until a new order from the treating physician has been received.

New Rule Contains Exceptions

"This is a concern because there are times when the treating physician can't be reached," Greeson says. "Perhaps the patient is at the diagnostic testing facility late in the day and the referring physician's office is closed. The radiologist, however, may determine that an alternative test may be more likely to yield the diagnostic information being sought or, after the initial test is performed, that a follow-up test may be indicated."
 
The new rules address this possibility, he adds, providing five conditions that, if met, permit the radiologist to proceed with unordered diagnostic services. These exceptions are applicable only when the ordered test produces abnormal results, Greeson cautions, not when the radiologist believes an alternative test is more appropriate or the preliminary test results are normal.
 
1. The IDTF or radiologist first performs the primary diagnostic test as ordered
 
2. After finding abnormal results from the ordered test, the radiologist documents the medical necessity for an additional diagnostic test
 
3. The radiologist shows that delaying the performance of the additional test would have an adverse effect on patient care
 
4. Once the additional test is performed, the radiologist must communicate findings to the treating physician, who then uses the information to treat the patient
 
5. The radiologist provides comprehensive documentation in the radiology report about why the additional testing was performed.

The CMS communiqu provides examples noting when these exceptions apply. A patient may be undergoing an abdominal CT scan with contrast (74160, computerized axial tomography, abdomen; with contrast material[s]), for instance, and the last slice shows a mass requiring a pelvic CT to further delineate the growth. If the treating physician is unavailable and all five conditions are met, the radiologist may proceed with the pelvic CT (e.g., 72193, computerized axial tomography, pelvis; with contrast material[s]).
 
The new rules provide three additional exceptions:
 
  • Radiologists are allowed to determine specific parameters of a diagnostic test without notifying the treating physician if those parameters are not specified in the original order (e.g., use or non-use of contrast material)
     
  • If a clear error has been made (e.g., the order asks for an x-ray of the left foot, but the patient's right foot was the appendage that had been injured), the radiologist may modify the order without notifying the referring physician
     
  • Radiologists may cancel a diagnostic test because the patient's condition will not permit performance of the test (a barium enema cannot be performed because of residual stool in the colon).

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