• E-mail
• Print
• PDF

Address test order protocol in hospital setting

Radiology Administrator's Compliance and Reimbursement Insider, November 1, 2008

Address test order protocol in hospital setting

Radiologists in freestanding imaging centers and private practice must get an order from a treating physician before they can perform a diagnostic imaging test for Medicare patients.

However, Medicare has different rules for hospital-based radiologists. The law permits them to order a test or modify a treating physician’s order on their own initiative—that is, without a treating physician’s order—but only under appropriate circumstances.

Nevertheless, many hospitals maintain internal policies or bylaws that require their radiologists to obtain an order from a treating physician. However, a policy change could benefit radiologists, patients, and your facility. A model protocol appears on p. 5 as an example of a simple, workable test-ordering policy.

What Medicare allows

The general rule under Medicare—that a radiologist must have a treating physician’s order to perform a diagnostic test—doesn’t apply to diagnostic tests performed in a hospital, says Thomas W. Greeson, Esq., a healthcare attorney at Reed Smith, LLP, in Falls Church, VA.

In the absence of specific regulations, use Medicare’s Conditions of Participation (CoP) for hospitals as a guide.

The CoP states that “radiologic service must be provided only on the order of practitioners with clinical privileges … authorized by the medical staff and the governing body to order the services.”

Because hospital-based radiologists are “practitioners with clinical privileges,” says Greeson, there’s no legal prohibition against their ordering tests.

There’s no reimbursement issue either, he says, because any radiologic procedure ordered, performed, and supervised by an appropriately credentialed radiologist would be a covered service when performed in a hospital setting.

Arguments for hospital order protocol

Highly trained and fully licensed radiologists should have the authority to “do the right thing” for their patients, Greeson says, adding that this includes ordering medically necessary tests and modifying existing orders.

Patient benefits include the following:

• Radiologists may order a more appropriate test than the exam requested by the treating physician. Technology in radiology develops so rapidly that it can be difficult to keep up. That’s one good reason for radiologists to order a test when they think it’s appropriate, says Leonard Berlin, MD, FACR, radiology department chair at Rush North Shore Medical Center in Skokie, IL.

A treating physician may order a test that he or she is familiar with when a newer test is more appropriate for the particular patient. In that case, everyone benefits from a modified test order, Berlin says.

• The radiologist may order a needed follow-up test more quickly than the treating physician. If a diagnostic test results in indications that may require a follow-up exam, the radiologist could order and perform that second test right away. Further, the patient’s signs and symptoms may indicate the need for an additional exam.

For example, Berlin says, the treating physician orders a CT scan of the abdomen. On review of the patient’s complaints, the radiologist thinks it would be a good idea to also obtain a CT scan of the pelvis.

The radiologist should be able to order and perform the test without waiting for a treating physician’s okay. That’s better for the patient and more cost-effective for the hospital, says Berlin.

Arguments against hospital order protocol

Although radiologists can legally order tests in a hospital setting, and the interests of patient care often favor additional tests, many hospitals and radiology departments require radiologists to get orders from treating physicians before performing diagnostic tests. They give the following two reasons, to which our experts respond:

• Fear of increased medical liability. Greater responsibility for ordering diagnostic tests will lead to greater malpractice liability, some radiologists argue. Treating physicians and hospitals argue that if the radiologist alters an order and a bad outcome ensues, the patient may sue the treating physician as well as hospital.

Greeson says these fears may be exaggerated. In fact, a patient who wants to sue is more likely to sue everyone who treated him or her, regardless of who made the error.

Radiologists can minimize individual liability by consulting the treating physician whenever possible, adding tests or modifying orders only when the treating physician is unavailable.

If radiologists take these steps, Greeson says there’s no reason the authority to order tests should increase liability. “The point of granting a radiologist authority to order tests is to make the radiologist a part of the treatment team for the benefit of patients, not to convert the radiologist into a treating physician,” he says.

• Political or cultural obstacles. Among older physicians in particular, there’s still a tendency to see radiologists as scientists as opposed to physicians, says Berlin, noting that some treating physicians don’t like the idea of radiologists having direct communication with their patients, much less suggesting a particular test or describing a treatment plan. He believes these cultural or political issues are behind many hospitals’ policies barring radiologists from ordering tests or modifying test orders.

Such ideas about radiologist–treating physician interaction have changed, Berlin says. Many younger physicians recognize that with radiologic technology developing so rapidly, it’s difficult for nonradiologists to keep up. In addition, as radiologists take a more active role in communicating with patients (for example, as required by the Mammography Quality Standards Act), treating physicians accept that radiologists have more direct patient contact. Treating physicians understand that radiologists aren’t going to undermine the physician-patient relationship but, instead, will augment it, says Berlin. He also believes that managed care has changed the physician-patient relationship—patients don’t go to the same physician for decades anymore. This change has lessened the degree of paternalism that treating physicians exert over their patients and has made them more open to the concept of having a radiologist on the treatment team.

Arguments to hospital policymakers

If your hospital’s policy doesn’t let its radiologists order a diagnostic test or modify an order without prior approval from the treating physician, you may want to change that policy, Greeson says. The way you go about it will depend on its origin.

The following are examples of policy origins and suggestions on how to effect change:

• Bylaws. Some hospitals’ bylaws bar the radiologist from ordering tests. In that case, you’ll need to get the medical staff to amend the bylaws.
• Credentials. Your hospital may not credential radiologists to order tests. In that case, you’ll have to approach the credentialing committee to make the change.
• Radiology department rules. Some radiology departments have rules that prevent radiologists from ordering tests. In that case, you’ll have to canvass the department chair and other radiologists in the department and, if necessary, convince them that it’s in everyone’s interests to make the change.

Adopt test-ordering protocol

You can use protocol language, such as our model protocol, to amend hospital bylaws, establish a new credentialing protocol, or change a radiology department rule. Like our model protocol, yours should:

• Permit radiologist to order tests and modify orders if medically appropriate. The treating physician is still the best source for the order of any test, Greeson says, and any protocol should reflect that. It’s medically appropriate, and it will help you convince your colleagues to adopt the protocol if it’s clear the radiologists aren’t trying to step on the treating physician’s toes, Berlin says.
• Require radiologists to inform the treating physician as soon as possible. Thorough documentation of the reasons for ordering any test or modifying an existing order will ease any fears, Greeson says.

Insider sources

Leonard Berlin, MD, FACR, chair, radiology department, Rush North Shore Medical Center, 9600 Gross Point Road, Skokie, IL 60076, 847/933-6111; Leonard_Berlin@rsh.net.

Thomas W. Greeson, Esq., Reed Smith, LLP, 3110 Fairview Park Drive, Suite 1400, Falls Church, VA 22042-4503, 703/641-4200; TGreeson@ReedSmith.com, www.reedsmith.com.

• E-mail to a Colleague
• Print