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Archive for August, 2011

Diagnostic Imaging Medicare Requirements Radiology Tests Supervision

Saturday, August 27th, 2011

Diagnostic Imaging – Medicare Requirements Radiology Test Coverage

We often get questions regarding the conditions of coverage for non-hospital (radiology group) coverage of diagnostic radiology services. Most questions involve the level of supervision that is required under Medicare rules and the requirements that a treating physician order the applicable test. Oftentimes, these questions are tied to issues relative to the Physician Self-Referral (Stark law) exception for diagnostic radiology services that are performed following a consultation request from another health care provider.

 There are three core requirements for a radiology test to be covered under Medicare. The test must be properly ordered by a treating physician (with limited exceptions), the test must be performed by an authorized supplier, and the test must be performed under the proper level of physician supervision. This article will briefly cover all three of the prerequisites to coverage of diagnostic radiology tests. The requirements described in this article apply to outpatient tests. Tests ordered in the hospital context are subject to slightly different rules and beyond the scope of this article.

 Who may order diagnostic radiology tests?

 he Medicare reimbursement rules have strict standards for determining who is authorized to order a diagnostic radiology test. The rules are different depending upon whether the provider is located in a hospital or in a non-hospital setting such as an independent diagnostic testing facility or physician’s office.

 Generally, in a non-hospital setting, a diagnostic radiology test must be ordered by the treating physician. The treating physician rule is located in the Medicare regulations and requires that the diagnostic test be ordered by the physician (or in certain circumstances a non-physician practitioner) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of the diagnostic radiology test in the management of the patient’s medical problem.

Generally, the radiologist performing the test is not permitted to order a diagnostic radiology test. There are certain exceptions to the treating physician rule which were described in Medicare Transmittal 80. Transmittal 80 describes limited circumstances where a radiologist is permitted to order a diagnostic test and still receive payment for the technical component under Medicare rules.

A radiologist is authorized to order a diagnostic mammography test based upon the results of an initial screening examination. Where the treating physician cannot be reached and this is documented in the patient’s chart , the testing facility may furnish additional diagnostic tests if the interpreting radiologist at the testing facility documents that there are abnormal results with the test originally ordered by the treating physician and that an additional test is medically necessary. In order to rely on this exception, the fact that the treating physician was not available and that additional tests were medically necessary should be well documented in the chart. This exception requires the results of the test to be communicated to the treating physician and used by the treating physician in treating the patient’s medical condition.

Where medically appropriate, the interpreting radiologist is also permitted to make determinations regarding the parameters of the diagnostic test contained in the initial order from the treating physician. In cases where there is a clear and obvious error in the initial order, the interpreting physician may make appropriate modifications. The intervening physician may also cancel orders based upon the patient’s medical condition at the time of the diagnostic tests.

Except for the limited circumstances described above and included in Transmittal 80, the radiologist must always rely upon the order that is made by the treating physician and may not independently order diagnostic radiology tests.

Who Is Qualified To Perform the Radiology Test?

The second major requirement for the coverage radiology services in a non-hospital setting is that only a qualified provider of the services may be reimbursed. Qualified providers include physicians, group practices of physicians, approved portable x-ray suppliers, independent diagnostic test testing facilities, nurse practitioners or clinical nurse specialists as authorized under state law, FDA certified mammography facilities, clinical psychologists for certain types of tests, qualified audiologists, pathology slide preparation facilities, clinical laboratories for certain tests, and radiation therapy centers.

Level of Physician Supervision For Diagnostic Imaging Tests

The last of the major requirements for coverage of radiology services is the level of physician supervision that is required given the specific test being performed. Radiology services must be provided under at least a general level physician supervision. Additionally, certain tests must be provided under direct or personal supervision, which require higher levels of physician presence and involvement. Failure to provide the appropriate level of physician supervision and to document the supervision in the chart will result in loss of coverage under Medicare and Medicaid. Any claims submitted in spite of not meeting the supervision requirements will be considered to be not reasonable or necessary by Centers for Medicare & Medicaid.

There are a few exceptions from the physician supervision requirements for certain limited types of tests. It must be kept in mind however that these exceptions are Medicare only exceptions and there may be other federal or state laws that apply to require physician supervision. Tests that are excepted from physician supervision requirements include diagnostic mammography procedures, diagnostic tests performed by a qualified audiologist and certain psychological tests.

You must determine whether general, direct or personal supervision is required in order to bill the applicable diagnostic radiology procedure. Failure to meet the appropriate supervision requirement will lead to loss of reimbursement. This can also be an area of potential civil money penalty exposure if billings are made in spite of there not having been appropriate supervision. Thus, the supervision requirement is a significant compliance issue for medical practices who must establish and maintain appropriate policies and procedures regarding supervision of various levels of radiology diagnostic tests.

Each level of supervision has very specific requirements that must be met. For this reason it is important to know which level of supervision is required for the specific test being performed. General supervision requires that the procedure be furnished under the physicians overall direction in control. Physician presence is not necessarily required during the performance of procedures that require general supervision. Under general supervision the physician is responsible for general supervision and training of support personnel who are actually performing the test services. The physician is also responsible for maintaining the necessary equipment and supplies for the safe operation of the diagnostic test.

Direct and personal supervision each require higher levels of physician involvement and generally require some level of physician presence throughout the performance of the test. Direct supervision in the office setting requires that the physician be present in the office suite and immediately available to furnish assistance. Physical presence in the office suite must be maintained throughout the entire performance of the procedure. The physician is not required to be physically present in the room where the procedure is performed unless there is a need for the physician’s presence due to some problem that arises during the course of performing the test.

The highest level of physician supervision is personal supervision. Personal supervision requires a physician to actually be present in the room during the performance of the procedure. Personal supervision generally involves diagnostic tests with invasive or otherwise dangerous aspects. One significant example of a test that requires personal supervision is contrast studies.

It is important to know what level of supervision is required for the test that is being performed. The level of supervision that is required for each test is included in the Physician Relative Value Fee Schedule. The CMS web site includes a spreadsheet that designates the level of supervision that is required for a variety of services including diagnostic imaging services. The spreadsheet includes a column for “physician supervision.” The column indicates a numerical value with “1” indicating general supervision, “2” indicating direct supervision and “3” indicating personal supervision.

Physician practices and compliance officers should be certain that their policies are in line with CMS requirements for coverage of diagnostic radiology tests. Radiology groups must be certain that the tests they are charged with performing meet each of the requirements stated above. Radiology groups need to be certain that the test is ordered by the treating physician unless inapplicable exception is present, and that the appropriate level of physician supervision is met for the type of test that is being performed.Health care attorneys health law

For more information regarding the requirements for radiology services and other legal issues that affect radiology practices and providers, please contact John Fisher, member of Ruder Ware’s Health Care Focus Team.

John Fisher is an experienced health care attorney who has practiced extensively in the health care industry providing counsel to a wide variety of health care providers. John has counseled health care clients, including hospitals, physicians, and health systems on health care regulatory compliance, contracts, mergers and acquisitions, joint ventures, recruitment and compensation issues, integrated network development, and Medicare and Medicaid reimbursement. John is knowledgeable on the laws and regulations that affect financial relationships between health care providers including the Stark Law, Anti-kickback Statute and safe harbor regulations, fraud and abuse, antitrust and exempt organization tax issues.

Accreditation Requirements – Advanced Diagnostic Imaging Services

Wednesday, August 17th, 2011

Advanced Diagnostic Imaging Service Accreditation Requirement

Providers of the technical component of advanced diagnostic imaging procedures will be subject to new accreditation requirements starting January 1, 2012.  Advanced diagnostic imaging procedures include diagnostic magnetic resonance imaging (MRI), computed tomography (CT), and nuclear medicine imaging such as positron emission tomography (PET).  X-ray, ultrasound, fluoroscopy procedures, and diagnostic and screening mammography are excluded from the accreditation requirement.

The 2008 law that created the accreditation requirement also required CMS to designate accrediting organizations.  CMS has approved three national accreditation organizations – the American College of Radiology, the Intersocietal Accreditation Commission, and The Joint Commission – to provide accreditation services for suppliers of the technical component of advanced diagnostic imaging procedures.

The accreditation requirement applies to all providers of advanced diagnostic imaging services, including physician offices that provide these services.  However, the accreditation applies only to the provision of the technical component and not the physician interpretation component of the procedures.

 There is also a potential billing implication to the new accreditation requirement.  It appears that the end result of requiring accreditation may be that the technical and professional component will not be able to be billed globally following the effective date of the accreditation requirement.  It appears that separate billing would be required due to the fact that the technical component will need to be billed with a “code 95” indicator while the professional component will not.  This billing issues has not been clarified by CMS.  Providers should seek guidance prior to the January 1, 2012 effective date.

The takeaway is that providers should not only deal with the accreditation requirement but must also re-examine how the services are billed.  This is particularly true in a physician practice that provides both the technical and professional component of advanced diagnostic imaging tests.

John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
500 First Street, Suite 8000
P.O. Box 8050
Wausau, WI 54402-8050

Tel 715.845.4336
Fax 715.845.2718

Ruder Ware is a member of Meritas Law Firms Worldwide

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