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UVMFLOWNET  March 2003

UVMFLOWNET March 2003

Subject:

Re: Help, please

From:

"Franklin W. West" <[log in to unmask]>

Reply-To:

UVM Flownet <[log in to unmask]>

Date:

Mon, 3 Mar 2003 08:47:12 -0800

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (155 lines)

Eileen,

http://cms.hhs.gov/manuals/pm_trans/R1787B3.pdf is the link to the CMS
Program Transmittal from 1/24/03 that revises the Medicare Carrier's Manual
(subsection 15021) regarding the ordering of diagnostic tests ... I'll
attempt to attach the pertinent subsections, but it may exceed the Flownet
line limit restriction ...

********************
Franklin W. West
PVI
425.398.7774 (voice)
425.486.8976 (fax)
[log in to unmask]
********************
MCM ? 15021. ORDERING DIAGNOSTIC TESTS
A. Definitions.--
1. A "diagnostic test" includes all diagnostic x-ray tests, all diagnostic
laboratory tests, and other diagnostic tests furnished to a beneficiary.
2. A "treating physician" is a physician, as defined in ?1861(r) of the
Social Security Act (the Act), who furnishes a consultation or treats a
beneficiary for a specific medical problem, and who uses the results of a
diagnostic test in the management of the beneficiary's specific medical
problem.
NOTE: A radiologist performing a therapeutic interventional procedure is
considered a treating physician. A radiologist performing a diagnostic
interventional or diagnostic procedure is not considered a treating
physician.
3. A "treating practitioner" is a nurse practitioner, clinical nurse
specialist, or physician assistant, as defined in ?1861(s)(2)(K) of the Act,
who furnishes, pursuant to State law, a consultation or treats a beneficiary
for a specific medical problem, and who uses the result of a diagnostic test
in the management of the beneficiary's specific medical problem.
4. A "testing facility" is a Medicare provider or supplier that furnishes
diagnostic tests. A testing facility may include a physician or a group of
physicians (e.g., radiologist, pathologist), a laboratory, or an independent
diagnostic testing facility (IDTF).
5. An "order" is 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). An order may include the following
forms of communication:
a. A written document signed by the treating physician/practitioner, which
is handdelivered, mailed, or faxed to the testing facility; NOTE: No
signature is required on orders for clinical diagnostic tests paid on the
basis of the physician fee schedule or for physician pathology services.
b. A telephone call by the treating physician/practitioner or his/her office
to the testing facility; and
c. An electronic mail by the treating physician/practitioner or his/her
office to the testing facility.
NOTE: If the order is communicated via telephone, both the treating
physician/practitioner or his/her office, and the testing facility must
document the telephone call in their respective copies of the beneficiary's
medical records.
B. Treating Physician/Practitioner Ordering of Diagnostic Tests.--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
which require performance of sequential tests.
C. Different Diagnostic Test.--When an interpreting physician, e.g.,
radiologist, cardiologist, family practitioner, general internist,
neurologist, obstetrician, gynecologist, ophthalmologist, thoracic surgeon,
vascular surgeon, at a testing facility determines that an ordered
diagnostic radiology test is clinically inappropriate or suboptimal, and
that a different diagnostic test should be performed (e.g., an MRI should be
performed instead of a CT scan because of the clinical indication), the
interpreting physician/testing facility may not perform the unordered test
until a new order from the treating physician/practitioner has been
received. Similarly, if the result of an ordered diagnostic test is normal
and the interpreting physician believes that another diagnostic test should
be performed (e.g., a renal sonogram was normal and based on the clinical
indication, the interpreting physician believes an MRI will reveal the
diagnosis), an order from the treating physician must be received prior to
performing the unordered diagnostic test.
D. Additional Diagnostic Test Exception.--If the testing facility cannot
reach the treating physician/practitioner to change the order or obtain a
new order and documents this in the medical record, then the testing
facility may furnish the additional diagnostic test if all of the following
criteria apply:
1. The testing center performs the diagnostic test ordered by the treating
physician/practitioner;
2. 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;
3. Delaying the performance of the additional diagnostic test would have an
adverse effect on the care of the beneficiary;
4. The result of the test is communicated to and is used by the treating
physician/practitioner in the treatment of the beneficiary; and
5. The interpreting physician at the testing facility documents in his/her
report why additional testing was done.
EXAMPLE: (a) The last cut of an abdominal CT scan with contrast shows a mass
requiring a pelvic CT scan to further delineate the mass; (b) a bone scan
reveals a lesion on the femur requiring plain films to make a diagnosis.
E. Interpreting Physician Exception.--This exception applies to an
interpreting physician of a testing facility who furnishes a diagnostic test
to a beneficiary who is not a hospital inpatient or  outpatient. The
interpreting physician must document accordingly in his/her report to the
treating physician/practitioner.
1. Test Design.--Unless specified in the order, the interpreting physician
may determine, without notifying the treating physician/practitioner, the
parameters of the diagnostic test (e.g., number of radiographic views
obtained, thickness of tomographic sections acquired, use or non-use of
contrast media).
2. Clear Error.--The interpreting physician may modify, without notifying
the treating physician/practitioner, an order with clear and obvious errors
that would be apparent to a reasonable layperson, such as the patient
receiving the test (e.g., x-ray of wrong foot ordered).
3. Patient Condition.--The interpreting physician may cancel, without
notifying the treating physician/practitioner, an order because the
beneficiary's physical condition at the time of diagnostic testing will not
permit performance of the test (e.g., a barium enema cannot be performed
because of residual stool in colon on scout KUB; PA/LAT of the chest cannot
be performed because the patient is unable to stand). When an ordered
diagnostic test is cancelled, any medically necessary preliminary or scout
testing performed is payable.
F. Surgical/Cytopathology Exception.--This exception applies to an
independent laboratory's pathologist or a hospital pathologist who furnishes
a pathology service to a beneficiary who is not a hospital inpatient or
outpatient, and where the treating physician/practitioner does not
specifically request additional tests the pathologist may need to perform.
When a surgical or cytopathology specimen is sent to the pathology
laboratory, it typically comes in a labeled container with a requisition
form that reveals the patient demographics, the name of the
physician/practitioner, and a clinical impression and/or brief history.
There is no specific order from the surgeon or the treating
physician/practitioner for a certain type of pathology service. While the
pathologist will generally perform some type of examination or
interpretation on the cells or tissue, there may be additional tests, such
as special stains, that the pathologist may need to perform, even though
they have not been specifically requested by the treating
physician/practitioner. The pathologist may perform such additional tests
under the following circumstances:
1. These services are medically necessary so that a complete and accurate
diagnosis can be reported to the treating physician/practitioner;
2. The results of the tests are communicated to and are used by the treating
physician/practitioner in the treatment of the beneficiary; and
3. The pathologist documents in his/her report why additional testing was
done.
EXAMPLE: A lung biopsy is sent by the surgeon to the pathology department,
and the pathologist finds a granuloma which is suspicious for tuberculosis.
The pathologist cultures the granuloma, sends it to bacteriology, and
requests smears for acid fast bacilli (tuberculosis). The pathologist is
expected to determine the need for these studies so that the surgical
pathology examination and interpretation can be completed and the definitive
diagnosis reported to the treating physician for use in treating the
beneficiary.

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