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D. Diagnostic Tests
1. Ordering of Diagnostic Tests In our November 22, 1996 final rule for the 1997 physician fee schedule (61 FR 59490), we revised Â§ 410.32 (Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions) to state that, to be covered, diagnostic tests had to be ordered by the physician who treats the patient.
An “order” is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:
A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility; NOTE: No signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services;
A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary‟s medical records. While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed.
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