The Centers for Medicare & Medicaid Services (CMS, formerly HCFA) announced much-anticipated modifications to the physician-ordering rule late in September. Although it provides for a number of specific exceptions, the rule reiterates CMS' position that radiologists may not change parameters of diagnostic tests or perform additional tests without a new order from the treating physician. While radiologists and professional coders see certain portions of the amended rule as a step in the right direction, most expressed disappointment that the rules remained as limiting as they did.
"I believe that most of us in the field had expected the ordering rules to be much less restrictive," says Thomas W. Greeson, a partner with Reed Smith, LLP in Falls Church, Va., whose client base is comprised of diagnostic-radiology groups, and formerly the general counsel for the American College of Radiology (ACR). "Radiologists are consulting physicians and are often the best qualified to determine the most appropriate diagnostic test to perform under the circumstances. The final result, however, does not provide the kind of flexibility most
radiology practices would have liked."
Traditionally, radiologists have been frustrated because they were allowed virtually no latitude in adjusting or amending a referring physician's order when it was clinically indicated. Professional organizations like the ACR and the Radiology Business Management Association (RBMA), along with individual radiologists, have lobbied for more leeway in obtaining diagnostic images. CMS has studied the issue throughout 2001, and radiology professionals were optimistic about the potential outcome. "There are circumstances when a radiologist encounters a roadblock when executing the physician's order," Greeson says. "We hoped the changes from CMS would provide greater alternatives in those situations."
Test Changes Require New Order
The modified rules, communicated through CMS Transmittal 1725, affect only radiology offices and independent diagnostic testing facilities (IDTFs) and not those tests conducted with hospital inpatients, outpatients or emergency-department patients, Greeson says. CMS defers to hospital policy and Joint Commission standards for ordering diagnostic tests in the hospital setting. The new rules have been codified in Section 15021 of the Medicare Carriers Manual under the heading of Ordering Diagnostic Tests. The policy clearly states that the treating physician must request specific diagnostic tests from the radiologist via a written document, e-mail, or a telephone call (which must be documented in both the treating physician's and the radiologist's copy of the medical record).
The order may also conditionally request an additional diagnostic test, depending on the outcome of the original order. For instance, the treating physician's orders might request that the radiologist perform a transabdominal pelvic ultrasound (e.g., 76856, echography, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete), followed by a transvaginal sonogram (76830, echography, transvaginal) if medically indicated based on [...]
