June 30, 2007

ACR Radiology Coding Source May-June 2007

Clarification on Ordering of Diagnostic Tests Rule, Supervision Rule and ICD-9 Coding Guidelines

In 2001, the American College of Radiology (ACR) was successful in its efforts to obtain clarification from the Centers for Medicare and Medicaid Services (CMS) on the Ordering of Diagnostic Tests rule (42 CFR 410.32) and ICD-9 coding for diagnostic tests. These two issues had been variably interpreted across the country by Carrier Medical Directors (CMDs), compliance officers and consultants, resulting in significant difficulty for radiologists and inconvenience for Medicare beneficiaries. CMS issued clarification on both issues to all its Medicare carriers through Transmittal 1725, which was later manualized into Section 15021 of the paper-based Medicare Carriers Manual (MCM). At this time, CMS is in the final stages of having this information placed into the Internet-Only Manual (IOM). Until the IOM is updated, radiology practices can refer to MCM 15021 of the paper-based manual, Part 3 Claims Process, Section b3_15000…t for guidance. 

Because of the importance of the Ordering of Diagnostic Tests rule, Supervision rule, and ICD-9 coding guidelines to radiology practices, the ACR Bulletin, November 2001, economics column is reprinted here for easy reference. 

The ACR had been concerned about Medicare carriers restricting radiologists’ ability to: 

Appropriately revise ordered tests (change, add to, or delete tests) based on the medical needs of the patient Submit ICD-9-CM codes based on clinical information obtained by the radiologist or radiology staff, or based on the findings of an imaging examination.

In addition, there had been considerable confusion about which rules apply to which sites of service (office versus hospital versus independent diagnostic testing facility [IDTF]). For example: 

Many consultants and hospital compliance officers were incorrectly insisting that CMS rules state that hospital outpatient departments must have a written order in hand before performing diagnostic tests.

A state fiscal intermediary had issued a statement that all CT and MR examinations done with contrast would be denied if the ordering physician had not written the order “with contrast.”

One CMD issued a statement that if an extremity radiographic examination was ordered (e.g., ankle x-ray), the lowest value study of that examination (two-view) would be reimbursed, if the ordering physician had not indicated that more views were needed.

Although efforts on these issues were already under way, in response to Resolution 47 of the 2000 ACR council, the College worked diligently with CMS for two years to articulate that the widespread misinterpretation of the Ordering of Diagnostic Tests” rule, the ICD-9 coding rules, and the different requirements for hospitals, outpatient freestanding centers, and IDTFs by many of the CMDs, auditors, and hospital compliance officers had been detrimental to the practice of radiology and had limited radiologists’ ability to promote appropriate and efficient imaging evaluations of Medicare beneficiaries. The perseverance by the ACR produced a clarification that has alleviated most of these misunderstandings. 

Clarification of “Ordering of Diagnostic Tests” Rule 
First issued in November of 1996, and clarified in the Federal Register, October 31, 1997, the “Ordering of Diagnostic Tests” rule defined the “treating physician” and indicated that all diagnostic tests must be ordered by the treating physician/practitioner. According to CMS,this policy was intended to prevent the practice of some testing facilities to routinely apply protocols which require performance of sequential tests

In response to the ACR’s repeated requests and the intensive work of its economics and health policy department, CMS clarified the following for all carrier medical directors in the Medicare Carriers Manual, Transmittal 1725: 

The “Ordering of Diagnostic Tests” rule does not apply to hospital inpatients or outpatients. [This was also confirmed in a letter from Thomas A. Scully, Administrator of CMS to the American Hospital Association, June 11, 2003.]

An order from the treating physician to the testing facility may be via written communication (hand delivered or faxed), e-mail, or telephone.

Additional testing may be done by the radiologist prior to or without contacting the referring physician, if certain criteria are met.

An order may conditionally request an additional diagnostic test for a particular beneficiary if the initial ordered test result yields a certain value (i.e., if test X is negative, then perform test Y).

As requested by the ACR, CMS also clarified in Section 15021 (E) of the MCM that a radiologist may perform the following without notifying the treating physician: 

Unless specified in the order, set the protocol for a given diagnostic, interventional, or therapeutic procedure ordered (e.g., number of radiographic views obtained, thickness of tomographic sections acquired, use or non-use of contrast media).

Modify an order with clear and obvious errors (e.g., x-ray of wrong foot ordered).

Cancel an order because the beneficiary’s physical condition at the time of the diagnostic testing will not permit performance of the test. Any medically necessary preliminary or scout studies performed prior to the cancelled order should be coded.

For example, a barium enema cannot be performed because of residual stool in the colon as identified on scout KUB. The scout KUB is payable by Medicare

Adding Additional Radiology Procedures 
If the radiologist determines that, based on the result of an ordered examination or procedure, an additional examination or procedure should be performed, and he or she is unable to reach the referring physician, additional diagnostic radiology tests may be obtained by the radiologist without obtaining a new order, if all of the following criteria are met: 

The diagnostic test ordered by the treating physician/practitioner is performed. 
The radiologist determines that an additional diagnostic test is medically necessary due to abnormal results of the diagnostic test performed. 
A delay in additional testing would have an adverse effect on the beneficiary. 
The treating physician is notified of the results of the test and uses the results in the treatment of the patient. 
The radiologist documents in the report why additional testing was necessary (It is critical to document the reason in reports of the original test and the added test.)

For example, a bone scan reveals a lesion on the femur requiring plain films to make a diagnosis, or the last cut of an abdominal CT scan with contrast shows a mass requiring pelvic CT scan to further delineate the mass

Changing the Ordered Test to an Entirely Different Test 
The transmittal states that a diagnostic testing facility that furnishes a diagnostic test ordered by the treating physician/practitioner may not change the diagnostic test ordered (e.g., CT to MRI) without a new order from the requesting physician. 

The ACR has commented repeatedly that radiologists are physicians who should be allowed to modify orders as they feel appropriate for the patient. CMS does not allow radiologists to change the originally ordered test because the radiologist may not know the true intent of the order or of previous studies performed on the patient prior to this request. In this case, written (e.g., e-mail, mail, or fax) or verbal (e.g., telephone) communication must occur prior to the change in order to obtain a new or revised order. 

Definition of an “Order” 
CMS defines an order as: 

Written communication (hand-delivered or faxed)

Telephone call

Electronic mail (e-mail) to the testing facility by the treating physician/practitioner or his or her staff.

If an order is communicated via telephone, both the treating physician and the testing site must document the telephone call in their respective copies of the patient’s medical record. 

Who is a “Treating Physician”? 
The Social Security Act defines a “treating physician” as a “physician who furnishes a consultation or treats a beneficiary for a specific medical problem, and who uses the results of a diagnostic test in the management of the beneficiary’s specific medical problem.” The ACR argued that the radiologist “manages” the imaging/interventional components of the patient’s medical care and thus should be considered a “treating physician.” 

The transmittal clarifies that a radiologist performing a therapeutic interventional procedure is considered a “treating physician,” and thus can order tests related to the condition for which the intervention is being performed. However, a radiologist performing a diagnostic or diagnostic interventional procedure is not considered a treating physician. 

Conditional Test Requests 
As described above, CMS has approved the use of conditional orders as long as they are limited to a specific beneficiary. For example, if a patient-specific order reads: “Diagnostic mammogram of right breast with ultrasound if mass identified,” the radiologist may add the ultrasound to characterize the mass. 

A standing order for all patients of a given requesting physician (e.g., “If gallbladder ultrasound for Dr. Smith’s patients are negative, do UGI”) is not acceptable. 

Clarification of ICD-9-CM Coding 
By law, the Balanced Budget Act (BBA) of 1997 requires that physicians or practitioners ordering diagnostic tests provide sufficient diagnostic information so that “testing entities” performing those tests can submit accurate claims. The ACR worked diligently to communicate with CMS that, when the referring physician does not provide appropriate clinical history for ICD-9 coding, radiologists are physicians who themselves, or through their staff, can talk with the patients to determine why they were referred for the test. Many misinterpretations of the “Ordering of Diagnostic Tests” rule as it applies to IDTFs (which cannot obtain this information) restricted radiologists from obtaining their own ICD-9 information to be reported on the Medicare claim form. Consequently, the physician who did not provide the clinical information per the BBA is not the one whose claim is denied. The ACR also argued that, like all other physicians, radiologists should be able to use the findings of their examinations to supply accurate and often specific information about clinical diagnoses. 

As a result, CMS issued PM B-01-144 (supersedes B-01-61) to all carriers and intermediaries on ICD-9-CM Coding for Diagnostic Tests. In this PM, effective January 1, 2002, CMS clarified: 

CMS supports the use of the Official ICD-9-CM Guidelines for Coding and Reporting.

The ICD-9 rules apply to the hospital outpatient and office settings.

Radiologists may code the findings from the radiology examination as a primary diagnosis on the CMS claim form (i.e., the radiologist may code the findings from the radiology examination as a primary diagnosis on the CMS claim form).

The ICD-9 clarification states that, when the interpreting physician does not have diagnostic information on the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient’s medical record. However, the PM states “that an attempt should be made to confirm any information obtained from the patient by contacting the referring physician.” The PM does not specify who in the interpreting physician’s office must obtain this information. 

The PM also addresses basic ICD-9 coding principles such as: 

An incidental finding may be reported as a secondary diagnosis, but never as a primary diagnosis (e.g., old rib fracture on chest x-ray).

Unrelated and coexisting conditions/diagnoses may be reported as additional diagnoses by the physician interpreting the diagnostic test but not as the primary diagnosis (e.g., AAA on abdominal ultrasound for jaundice).

Tests performed without clinical signs or symptoms for screening purposes should be reported with the appropriate screening ICD-9 code as the primary diagnosis. The results of the test may be reported as additional or secondary diagnoses.

The PM reminds carriers that all diagnoses must be coded to the highest level of specificity (i.e., the most precise ICD-9-CM code that most fully explains the narrative description of the symptom or diagnosis). 

For example, assign three-digit codes only if there are no four-digit codes within a code category; assign four-digit only if there are no five-digit code;s and assign five-digit codes if they exist. 

The result is that radiologists now can submit ICD-9-CM clinical diagnoses in accordance with the ICD-9-CM guidelines for coding and reporting, as do all physicians. The coding guidelines document contains many useful examples. For a copy of the official ICD-9 coding guidelines, go to the Centers for Disease Control Web site

Also reference the Medicare Claims Processing Manual, Chapter 23 - Section 10 – Fee Schedule Administration and Coding Requirements, which addresses ICD-9-CM Coding for Diagnostic Tests. 

Supervision Rule 
In response to the ACR comment letter of July 16, 2001, (LINK) Transmittal 1725 also clarified two important points on the supervision rule implemented on July 1, 2001. The supervision rule does not pertain to hospital inpatients or outpatients. Also, nurse practitioners, clinical nurse specialists, and physician assistants may not function as supervisory physicians; however, they may perform diagnostic tests under their own statutory benefits and state requirements for physician supervision. 

The ACR had also commented that all ultrasound and nuclear medicine procedures should require direct supervision where the physician is in the facility or available by teleradiology, to check procedural setup and protocol and monitor the images obtained for quality assurance. However, CMS retained its position on general supervision for nuclear medicine and ultrasound and further downgraded the supervisory level of 13 ultrasound codes. Diagnostic ultrasound procedures such as echoencephalography (76506), ophthalmic biometry (76516, 76519), ophthalmic foreign body localization (76529), spine (76800), pelvis (76805-76816, 76825), and extremity (76885), which required direct supervision, have been changed to general supervision. 

Click here for a listing of supervision levels as noted in the 2007 Medicare Physician Fee Schedule.