The treating physician/practitioner must order all diagnostic tests furnished to a beneficiary who is not an institutional inpatient or outpatient. A testing facility that furnishes a diagnostic test ordered by the treating physician/practitioner may not change the diagnostic test or perform an additional diagnostic test without a new order. This policy is intended to prevent the practice of some testing facilities to routinely apply protocols that require performance of sequential tests.
Different Radiology Diagnostic Test
When an interpreting physician (e.g., radiologist, cardiologist, family practitioner, general internist, neurologist, obstetrician, gynecologist, ophthalmologist, thoracic surgeon, vascular surgeon) at a testing facility determines that an ordered diagnostic radiology test is clinically inappropriate or suboptimal, and that a different diagnostic test should be performed (e.g., an MRI should be performed instead of a Computed Tomography (CT) scan because of the clinical indication), the interpreting physician/testing facility may not perform the unordered test until a new order from the treating physician/practitioner has been received.
Similarly, if the result of an ordered diagnostic test is normal and the interpreting physician believes that another diagnostic test should be performed (e.g., a renal sonogram was normal and based on the clinical indication, the interpreting physician believes an MRI will reveal the diagnosis), an order from the treating physician must be received prior to performing the unordered diagnostic test.
Additional Diagnostic Radiology Test Exception
If the testing facility cannot reach the treating physician/practitioner to change the order or obtain a new order and documents this in the medical record, then the testing facility may furnish the additional diagnostic test if all of the following criteria apply:
* The testing center performs the diagnostic test ordered by the treating physician/practitioner.
* The interpreting physician at the testing facility determines and documents that, because of the abnormal result of the diagnostic test performed, an additional diagnostic test is medically necessary.
* Delaying the performance of the additional diagnostic test would have an adverse effect on the care of the beneficiary.
* The result of the test is communicated to and is used by the treating physician/practitioner in the treatment of the beneficiary.
* The interpreting physician at the testing facility documents in his report why additional testing was done.
Example: (a) The last cut of an abdominal CT scan with contrast shows a mass requiring a pelvic CT scan to further delineate the mass.
(b) A bone scan reveals a lesion on the femur requiring plain films to make a diagnosis.