Part B Insider (Multispecialty) Coding Alert

Published on Sat Apr 11, 2009 PDF

Know CMSs allowable circumstances when a non-hospital radiologist can perform and bill for an exam without the treating physicians order.

Question: I have the 2001 CMS transmittal that explains when a radiologist may perform an exam without an order, but does CMS include this information in one of the current manuals?

Answer: Youll find the information youre looking for in the Medicare Benefit Policy Manual, Chapter 15, Section 80.6 (available on the internet at www.cms.hhs.gov/Manuals/IOM/list.asp).

There are only a few circumstances where a non-hospital radiologist may perform and charge for an exam without first getting an order from the treating physician.

Years ago, Medicare set out a general rule that the radiologist should seek a new order from the treating physician when he thinks he should perform a different diagnostic test because the test is inappropriate or doesnt offer a diagnosis. This is in the transmittal you refer to: www.cms.hhs.gov/transmittals/downloads/R1725B3.pdf.

CMS also offered an Additional Diagnostic Radiology Test Exception, allowing the radiologist to furnish the additional test if the testing facility cant reach the treating practitioner to change the order, if you meet the following:

" You perform the ordered test

" The interpreting physician determines and documents that abnormal test results make the additional test medically necessary

" Delay would harm the patient

" You send the treating physician the test result and he uses it in the treatment

" The radiologist documents the reason for the additional tests.

The radiologist also may determine test design if it isnt specified,modify an order that has clear errors,and cancel a test if the patients condition requires it.