Wiki New order needed?

[pattijo5116]

This scenario comes up rather frequently and is causing some confusion as to the correct procedure, could you please advise us regarding valid orders? As an Independent Testing Facility we receive an order from a treating physician for a patient to have a screening mammogram with breast ultrasound if indicated. Mammogram and ultrasound are done and based on these results the radiologist recommends the patient come back for spot compression views, and then for a 3 month follow-up ultrasound. 1
1) Can the compression views be done using the original mammogram order or would we need a separate order specifically for this test from the patients physician?
2) As for the 3 month follow up ultrasound, could we use the original order for this test or would we need a new order from the patients physician?

Thank you for your time on this matter.

 

[Chelle-Lynn]

A referral from theprimary care physician can cover a period from 30 days to one year. Generallythe length of time is determined by the policies of the individual medicalcarrier or insurance. In most casescarriers will allow 6 months for most referrals. In other cases you will see that the referralform from the PCP will have a “from” and “through” date that specifies thelength of the referral.
I would suggest checkingwith your contracted insurance carriers to see if there are any restrictions basedon timeframe. The most common timeframesare 30-60-90-120-180 days.

 

[pattijo5116]

Thank you very much for your reply. I been asked to explain this to my coworkers, so to be sure I understand correctly: as long as we have the initial order for the screening mammogram and ultrasound and the date on that initial order is within the policy timeframe of the carrier, we are allowed to perform the screening mammo as well as order further testing such as diagnostic mammograms, ultrasounds, etc, without going back through the PCP or without obtaining new orders for these additional tests? This is our confusion because the only references we can find in the CMS Policy Manual state that all diagnostic tests have to be ordered by the treating physician, and that the interpreting radiologist is not considered a treating physician. Could you possible suggest where I could find this clarification? Thank you again for all your help.

 

[Chelle-Lynn]

You are correct that for CMS only the screening mammogram can be self referred. If the next step is a diagnostic mammogram then a new referral/order from the treating provider will be required. However, for your private insurances, it would be best to check with them on their policies as they can vary from carrier to carrier. In most cases they will require a treating physician for the diagnostic mammogram to ensure that there is a physician following up with the patient on the results and any needed treatment.