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Use appropriate orders for diagnostic radiology testing

Radiology Administrator's Compliance and Reimbursement Insider, August 1, 2006

Federal regulations guide test orders

Q: Where can we find the federal regulations regarding radiology orders in the hospital setting? My radiologist wants to see written documentation that states that he can add procedures to the referring physician’s orders if he deems them medically necessary.

A: Consult the Hospital Conditions of Participation, 42 CFR 482.26 atwww.access.gpo.gov/nara/cfr/waisidx_02/42cfr482_02.html, says Stacie L. Buck, RHIA, CCS-P, LHRM, vice president of Southeast Radiology Management in Stuart, FL.

Radiologist or referring physician

Q: Should we allow our radiologists to order additional tests without an order from the attending physician?

A: “The short answer is yes—if the additional test is medically necessary,” Buck says.

And, adds Stacy Gregory, RCC, CPC, of Gregory Medical Consulting Services in Tacoma, WA, a radiologist can only order additional tests in the hospital setting under certain circumstances, as outlined in 482.26.

There is a distinct difference between hospital and nonhospital regulations, says Buck. In the nonhospital setting, you can only order additional tests if one of the exceptions to the test order rules exists.

Hospitals should also address this scenario in their bylaws. If you can obtain an order from the referring physician, then do so, Buck says. “Remember, protocols are not allowed. Medical necessity always prevails. And be sure that everything is documented.”

Order errors

Q: Can the radiologist change the physician orders in the physician setting if they are clearly wrong according to the patient’s clinical signs and symptoms (e.g., clinical indications call for CT angiography rather than CT)? Does the ordering physician have to be notified or issue another order?

A: CMS’ ordering of diagnostic tests rule (Medicare Carriers Manual 15021, Transmittal 1725) provides for “clear error,” says Gregory.

The document states that “the interpreting physician may modify, without notifying the treating physician/practitioner, an order with clear and obvious errors that would be apparent to a reasonable layperson [e.g., x-ray of wrong foot ordered].”

This scenario may also fall under the “test design” exception to the rules for ordering diagnostic tests, Gregory says.

“Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test [e.g., number of radiographic views obtained, thickness of tomographic sections acquired, and use or nonuse of contrast media].”

Find diagnostic test supervision and ordering requirements for hospitals in 42 CFR.

Adequate orders in a hospital setting

Q: Can a radiologist in a hospital-based radiology department order additional radiology procedures if the requested scan would not provide the medical information necessary to help the patient?

A: “Yes, this is [appropriate] in the hospital setting,” says Gregory.

The radiologist should always try to consult with the referring physician. But in the interest of patient care, if additional/different procedures need to be performed, the radiologist may order and provide these services in the hospital setting “with a written order and medical necessity, of course,” she says.

Breast ultrasounds are an exception to that rule, warns Gregory. A radiologist cannot order a breast ultrasound on a patient presenting for a diagnostic mammogram. That order needs to come from the patient’s treating physician.

Q: For a mammography requiring further evaluation, should the referring physician provide a new order for ultrasound of the breast, or can the radiologist order the ultrasound based on findings? Does he or she need to write a new order or just dictate the need?

A: A radiologist can request that a screening mammography be converted to a diagnostic mammography, but he or she cannot order the breast ultrasound, Gregory says. The order for the breast ultrasound must be generated by the referring physician.

Q: Who should be listed as the ordering physician if the radiologist appropriately adds procedures—the radiologist or the original referring physician?

A: The radiologist, says Gregory.

Insider sources:

Stacie L. Buck, RHIA, CCS-P, LHRM, vice president, Southeast Radiology Management, 512 SW, St. Lucie Crescent, Stuart, FL 34994, 772/600-0324; stacie@southeastrad.com; www.seradmgt.com.

Stacy Gregory, RCC, CPC, principal, Gregory Medical Consulting Services, 4653 North Bristol St., Tacoma, WA 98407-2014, 253/566-2494; stacygregory@wamail.net.

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