In general, I agree with Jack. For Part B claims, the following is the rule (with
a few <SNIP>s of irrelevant content to comply with listserve length
requirements). Also, CMS has "manualized" (have to love that word - from CMS)
allowing 'conditional' orders (e.g., 'if x is (insert test result), then do y' -
so something like "do 93922 and if normal do 93924" - maybe translated to
English?). The manuals provide more detailed, and useful (personal opinion)
guidance. In general, 'standing orders' are coming under increasing scrutiny -
with recommendations that physicians review and at least initial them in each case.
Franklin W. West
BSN, RN, RVT, RVS, FSVU, CHC
Director, Professional Services
Pacific Vascular Inc.
18702 N. Creek Parkway, Suite 212
[log in to unmask]
[Code of Federal Regulations] [Title 42, Volume 2]
TITLE 42--PUBLIC HEALTH
PART 410_SUPPLEMENTARY MEDICAL INSURANCE (SMI) BENEFITS--Table of Contents
Subpart B_Medical and Other Health Services
Sec. 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other
diagnostic tests: Conditions.
(a) Ordering diagnostic tests. All diagnostic x-ray tests, diagnostic
laboratory tests, and other diagnostic tests must be ordered by the physician who
is treating the beneficiary, that is, the physician who furnishes a consultation
or treats a beneficiary for a specific medical problem and who uses the results in
the management of the beneficiary's specific medical problem. Tests not ordered by
the physician who is treating the beneficiary are not reasonable and necessary
(see Sec. 411.15(k)(1) of this chapter).
(1) Chiropractic exception. <SNIP>
(2) Mammography exception. <SNIP>
(3) Application to nonphysician practitioners. Nonphysician practitioners
(that is, clinical nurse specialists, clinical psychologists, clinical social
workers, nurse-midwives, nurse practitioners, and physician assistants) who
furnish services that would be physician services if furnished by a physician, and
who are operating within the scope of their authority under State law and within
the scope of their Medicare statutory benefit, may be treated the same as
physicians treating beneficiaries for the purpose of this paragraph.
(b) Diagnostic x-ray and other diagnostic tests--(1) Basic rule. Except as
indicated in paragraph (b)(2) of this section, all diagnostic x-ray and other
diagnostic tests covered under section 1861(s)(3) of the Act and payable under the
physician fee schedule must be furnished under the appropriate level of
supervision by a physician as defined in section 1861(r) of the Act. Services
furnished without the required level of supervision are not reasonable and
necessary (see Sec. 411.15(k)(1) of this chapter).
(2) Exceptions. The following diagnostic tests payable under the physician fee
schedule are excluded from the basic rule set forth in paragraph (b)(1) of this
(i) Diagnostic mammography procedures, which are regulated by the Food and
(ii) Diagnostic tests personally furnished by a qualified audiologist as
defined in section 1861(ll)(3) of the Act.
(iii) Diagnostic psychological testing services when--
(A) Personally furnished by a clinical psychologist or an independently
practicing psychologist as defined in program instructions; or
(B) Furnished under the general supervision of a physician or a clinical
(iv) Diagnostic tests (as established through program instructions) personally
performed by a physical therapist who is certified by the American Board of
Physical Therapy Specialties as a qualified electrophysiologic clinical specialist
and permitted to provide the service under State law.
(v) Diagnostic tests performed by a nurse practitioner or clinical nurse
specialist authorized to perform the tests under applicable State laws.
(vi) Pathology and laboratory procedures listed in the 80000 series of the
Current Procedural Terminology published by the American Medical Association.
(3) Levels of supervision. Except where otherwise indicated, all diagnostic x-
ray and other diagnostic tests subject to this provision and payable under the
physician fee schedule must be furnished under at least a general level of
physician supervision as defined in paragraph (b)(3)(i) of this section. In
addition, some of these tests also require either direct or personal supervision
as defined in paragraphs (b)(3)(ii) or (b)(3)(iii) of this section, respectively.
(However, diagnostic tests performed by a physician assistant (PA) that the PA is
legally authorized to perform under State law require only a general level of
physician supervision.) When direct or personal supervision is required, physician
supervision at the specified level is required throughout the performance of the
(i) General supervision means the procedure is furnished under the physician's
overall direction and control, but the physician's presence is not required during
the performance of the procedure. Under general supervision, the training of the
nonphysician personnel who actually perform the diagnostic procedure and the
maintenance of the necessary equipment and supplies are the continuing
responsibility of the physician.
(ii) Direct supervision in the office setting means the physician must be
present in the office suite and immediately available to furnish assistance and
direction throughout the performance of the procedure. It does not mean that the
physician must be present in the room when the procedure is performed.
(iii) Personal supervision means a physician must be in attendance in the room
during the performance of the procedure.
(c) Portable x-ray services. <SNIP>:
(3) The procedures are limited to--
(ii) <SNIP> Chest; and
(iii) Diagnostic mammograms if <SNIP>
(d) Diagnostic laboratory tests--(1) <SNIP>:
(i) A participating hospital or participating RPCH.
(iv) An RHC.
(v) A laboratory, <SNIP>.
(vi) An FQHC.
(vii) An SNF <SNIP>
(2) Documentation and recordkeeping requirements--(i) Ordering the service.
The physician or (qualified nonphysican practitioner, as defined in paragraph (a)
(3) of this section), who orders the service must maintain documentation of
medical necessity in the beneficiary's medical record.
(ii) Submitting the claim. The entity submitting the claim must maintain the
(A) The documentation that it receives from the ordering physician or
(B) The documentation that the information that it submitted with the claim
accurately reflects the information it received from the ordering physician or
(iii) Requesting additional information. The entity submitting the claim may
request additional diagnostic and other medical information to document that the
services it bills are reasonable and necessary. If the entity requests additional
documentation, it must request material relevant to the medical necessity of the
specific test(s), taking into consideration current rules and regulations on
(3) Claims review. (i) Documentation requirements. Upon request by CMS, the
entity submitting the claim must provide the following information:
(A) Documentation of the order for the service billed (including information
sufficient to enable CMS to identify and contact the ordering physician or
(B) Documentation showing accurate processing of the order and submission of
(C) Diagnostic or other medical information supplied to the laboratory by the
ordering physician or nonphysician practitioner, including any ICD-9-CM code or
narrative description supplied.
(ii) Services that are not reasonable and necessary. If the documentation
provided under paragraph (d)(3)(i) of this section does not demonstrate that the
service is reasonable and necessary, CMS takes the following actions:
(A) Provides the ordering physician or nonphysician practitioner information
sufficient to identify the claim being reviewed.
(B) Requests from the ordering physician or nonphysician practitioner those
parts of a beneficiary's medical record that are relevant to the specific claim(s)
(C) If the ordering physician or nonphysician practitioner does not supply the
documentation requested, informs the entity submitting the claim(s) that the
documentation has not been supplied and denies the claim.
(iii) Medical necessity. The entity submitting the claim may request
additional diagnostic and other medical information from the ordering physician or
nonphysician practitioner to document that the services it bills are reasonable
and necessary. If the entity requests additional documentation, it must request
material relevant to the medical necessity of the specific test(s), taking into
consideration current rules and regulations on patient confidentiality.
(4) Automatic denial and manual review. (i) General rule. Except as provided
in paragraph (d)(4)(ii) of this section, CMS does not deny a claim for services
that exceed utilization parameters without reviewing all relevant documentation
that is submitted with the claim (for example, justifications prepared by
providers, primary and secondary diagnoses, and copies of medical records).
(ii) Exceptions. CMS may automatically deny a claim without manual review if a
national coverage decision or LMRP specifies the circumstances under which the
service is denied, or the service is specifically excluded from Medicare coverage
(e) Diagnostic laboratory tests furnished in hospitals and CAHs. <SNIP>
From: UVM Flownet [mailto:[log in to unmask]] On Behalf Of Jack I. Siegel
Sent: Wednesday, January 28, 2009 7:38 AM
To: [log in to unmask]
Subject: Re: PVR's vs duplex
That's fine if "your doctors" have a standing order that they would back you up
during an audit.
Any other physician needs to be contacted to get prior authorization for adding a
Treadmill, or your lab will get burned if audited.
Jack I. Siegel, BA RVT
Dartmouth Hitchcock Medical Center, NH
Veterans Administration Medical Center, VT
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