CODING Q&A

Diagnostic Tests Receiving Greater Scrutiny — Are Yours up to Snuff?

SUZANNE L. CORCORAN, COE

Within the Medicare program, ophthalmologists and optometrists receive reimbursement for a diagnostic test in about 90% of all eye exams. An important aspect of testing is the order for the service. As Medicare and other third-party payers increase scrutiny of charts and claims, a clearer understanding of long-standing and new regulations on this subject is helpful.

Q. Who may order diagnostic tests?

A. A provider “orders” non-physician items or services for the Medicare beneficiary, such as clinical laboratory services or imaging services. Medicare Part B uses the term “ordering/referring provider” to denote the person who ordered, referred, or certified an item or service reported on a claim. Only Medicare-enrolled individuals or certain other providers may order/refer, including physicians and other qualified healthcare professionals, such as physician assistants and nurse practitioners.

Q. What has changed?

A. The national provider identifier (NPI) for the individual physician is an essential part of a claim for reimbursement for ordered items and services; it is entered in box 17 of the CMS-1500 claim form or electronic equivalent. Section 1862(s)(2)(A) of the Social Security Act specifies that services and supplies furnished as “incident to” a physician’s professional service are “of kinds which are commonly furnished in physicians’ offices and are commonly either rendered without charge or included in physicians’ bills.” In 2016, the NPI on a claim for reimbursement of “incident to” services and supplies, including diagnostic tests, is more strictly regulated.

The CY 2016 Physician Fee Schedule Final Rule amended the incident to regulations to state explicitly that only the physician or other practitioner who directly supervises the auxiliary personnel who provide the incident to services may bill Medicare for these services. The Centers for Medicare and Medicaid Services do not require that the supervising practitioner be the same individual who orders or refers the beneficiary for the services or who initiates treatment. Rather, CMS requires that, under circumstances in which the supervising practitioner is not the same as the referring, ordering, or treating practitioner, only the supervising practitioner may bill Medicare for the “incident to” service.

Q. What supports an order for a diagnostic test?

A. The medical rationale for diagnostic testing starts with the examining physician’s need for more information than is attainable from the patient’s history and exam. CMS defines an order as “communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary.” This can be for tests ordered from an outside entity, such as laboratory work, or for tests to be performed within your own office.

The Code of Federal Regulations further states, “All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.”¹

A test personally performed by the physician does not need an order. For example, extended ophthalmoscopy cannot be delegated to auxiliary health personnel, so an order isn’t necessary — the ophthalmologist does it.

Q. We’ve heard that an exam must take place before a test is ordered. Is this always required?

A. Usually, but there are exceptions. In most cases, the physician’s examination of a patient leads to an order for one or more diagnostic tests, which may be performed on the same day or later. Occasionally, the ophthalmologist’s order for a test precedes the exam, such as when it is based on information about the patient received prior to a face-to-face encounter. Several scenarios illustrate this concept.

You receive a copy of chart notes from a referring doctor who asks for a consultation; after reviewing the chart, you order a diagnostic test to be administered on the patient’s arrival.

Your technician takes a history from a new patient and finds something concerning. The technician brings the information to you, the physician scheduled to see this patient soon, and you order an immediate diagnostic test based on the technician’s information.

A patient calls and speaks to the physician, who orders a diagnostic test based on the phone call.

Q. What are indications for testing?

A. The initial decision to order a test is motivated by a suspicion of a disease or illness due to patient symptoms, clinical signs, and/or prior medical history suggestive of a disease process. Testing without a suspicion of a disease or illness is considered screening and is not usually covered. An order, based on individual information about the patient, must designate a valid clinical reason for the diagnostic study. Together, the results of the testing with other data can help the physician plan appropriate therapeutic intervention.

Q. What about retesting?

A. Repeat testing is necessitated by disease progression, the occurrence of a new disease, or planning for additional surgical treatment. Repeated tests of the same, unchanged condition are usually unwarranted. Too-frequent testing can garner unwanted attention from Medicare and other payers. RP

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