Tip: Obtain necessary information to determine medical necessity for diagnostic tests
Compliance Monitor, July 28, 2004
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To prove medical necessity when ordering a diagnostic test, referring physicians must:
1. order all x-rays, diagnostic laboratory tests, and other diagnostic tests. Tests not ordered by the physician who treats the beneficiary are not reasonable and necessary.
2. provide diagnostic information to the testing entity when ordering the test. Referring physicians do not have to include diagnosis codes on referral slips or requests for radiological or other diagnostic tests, but they must include a narrative of the reason for the test.
In addition, facilities must report information on the patient's diagnosis when billing Medicare. In most cases, Medicare uses either the ICD-9-CM code assigned to the signs/symptoms or the definitive diagnosis to determine medical necessity.
Medicare gleans this information from the test or order, so be sure a diagnosis or a list of signs/symptoms with orders is included.
This tip was excerpted from the Medical Necessity Training Handbook for Nurses and Hospital Staff. Copyright 2004 by HCPro. For more information, click here.
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