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RTs play a critical role in the revenue cycle

Radiology Administrator's Compliance and Reimbursement Insider, September 1, 2005

In the initial phases of a patient's encounter at a facility, radiologic technologists (RT) must collect accurate information and question any discrepancies. Their diligence at this stage-on the frontlines of patient care-aids your facility in getting reimbursed properly for studies and complying with regulations such as Medicare. One mistake could cost the facility thousands of dollars.

RTs are often the only clinical individuals with whom a patient comes into contact during outpatient diagnostic testing. For this reason, RTs are key players in ensuring compliance regarding documentation and coding.

Because RTs possess clinical knowledge and insight that clerical personnel do not, it is their responsibility to document patient information with appropriate medical terminology and to question whether a specific diagnostic test is clinically appropriate or medically necessary based on a patient's history.

RTs' clinical knowledge and understanding of testing protocols allows them to raise questions regarding these matters and communicate effectively with physicians.

Obtaining and documenting the patient's history is important for diagnostic tests performed on an outpatient basis-particularly when ordering physicians have not provided a reason for the tests and you cannot reach them for additional information.

Therefore, before performing a diagnostic exam, RTs must take the following steps:

1. Query the patient about any symptoms he or she is currently experiencing; in other words, find out why the patient is having the test and ask about any past or chronic health conditions that may affect the exam

2. Ask whether the patient has had any adverse reactions to contrast materials during past exams

The treating/referring physician must order all diagnostic tests. According to CMS, any of the following may constitute an order:

When referring physicians do not provide diagnostic information that documents the reason for the test, the RT should ask the patient why his or her physician ordered the test or check the patient's medical record. If the RT takes information directly from the patient, he or she must make a concerted effort to verify it by contacting the referring physician.

Technologists should also understand the following before completing a diagnostic study:

1. All diagnostic tests-including x-ray, diagnostic laboratory, and others-must be ordered by a physician who treats the patient-that is, a physician who furnishes a consultation or treats a beneficiary for a specific medical problem and uses the results when managing that problem. The Code of Federal Regulations (42 CFR 410.32) specifies this requirement. Tests not ordered by a physician treating the patient are not reasonable and necessary.

Note: If you work in an independent diagnostic testing facility (IDTF), the ordering physician must order all exams in writing. There are two exceptions to this rule. First, you do not need to have orders for screening mammograms signed, and second, some states allow allied health practitioners to sign orders for certain referrals. Check your state's requirements.

2. Ordering physicians must provide diagnostic information to the testing entity at the time the physician orders the test. However, physicians are not required to include actual diagnosis codes on referral slips or requests for radiological or other diagnostic tests. The RT should ensure that these referral slips or requests include a narrative description that notes the reason for the test.

3. Medicare requires all providers to report information about a patient's diagnosis when seeking payment. This information helps the government-contracted fiscal intermediary (FI) or carrier determine whether the ordered services were medically necessary. RTs play a pivotal role in medical necessity checks and balances.

In most cases, the Medicare FI or carrier makes a medical necessity determination based on the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) code that your facility assigns to signs, symptoms, or definitive diagnoses. This information often comes directly from the order for the test or service-and a valid order must contain a diagnosis, signs, or symptoms.

Test ordering requirements are more stringent for physician offices, imaging centers, and IDTFs than for hospitals. The rules in the following section do not pertain to hospital inpatients or outpatients.

A testing facility that furnishes a diagnostic test ordered by the treating physician or practitioner may not change the diagnostic test or perform an additional diagnostic test without a new order. This policy prevents testing facilities from routinely applying protocols that require performance of sequential tests. An order may conditionally request an additional diagnostic test only if

Whether you or the radiologist determines that an ordered diagnostic radiology test is clinically inappropriate or suboptimal-and that a different diagnostic test should be performed-you may not perform the unordered test until your office receives a new order from the treating physician/practitioner.

For example, if you believe that a magnetic resonance imaging (MRI) text should be performed instead of the CT scan the physician ordered because of the patient's clinical indication, talk to the radiologist and do not perform either test until the new order arrives.

Similarly, if the result of an ordered diagnostic test is normal and the radiologist believes that another diagnostic test should be performed, the RT should wait for an order from the treating physician before performing the unordered diagnostic test.

For example, if a renal sonogram was normal, but based on the clinical indication, the radiologist believes a MRI will reveal the diagnosis, the RT should follow the protocol above and wait for a new order before performing an MRI.

If you cannot reach the ordering physician/practitioner to change an order or obtain a new one-and RTs document this attempt in the patient's medical record-then the RT may conduct the additional diagnostic test if all of the following occur:

Common situations you may encounter in which physicians may not be available include when

Follow the protocol above for these cases when you cannot reach the ordering/treating physician.

Editor's note: This story is an excerpt from HCPro's new book, Radiology Technologist's Coding Compliance Training Handbook, written by RACRI advisory board member Stacie Buck, RHIA, LHRM. To order a copy, call our Customer Service Department at 800/650-6787 or go to www.hcmarketplace.com.

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