Radiology Coding Alert

This exception applies to a radiologist of a testing facility who furnishes a diagnostic test to a beneficiary who is not a hospital inpatient or outpatient. The radiologist must document accordingly in his or her report to the treating physician/practitioner. Within a hospital facility the radiologist may modify any test for outpatients or inpatients without any restrictions. In all cases it is considered good medical practice to include the reasons for test customization in the imaging report.

Furthermore, the treating physician/practitioner must order all diagnostic tests furnished to a beneficiary who is not an institutional inpatient or outpatient. 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. This policy is intended to prevent the practice of some testing facilities to routinely apply protocols that require performance of sequential tests.

These requirements do not apply to hospitals, where the radiologist is considered one of the consulting or treating physicians in the hospital setting and can modify exams as he or she deems necessary. Guidelines relating to diagnostic test orders can usually be found in the medical staff bylaws of a facility.

Reader Questions and You Be the Coder were answered by Stacie L. Buck, RHIA, internal auditor for U.S. Diagnostic Inc., a corporation based in West Palm Beach, Fla.; and reviewed by Gary Dorfman, MD, FACR, SIR, president of Health Care Value Systems in North Kingstown, R.I.; and Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based firm.