(Medicare Benefit Policy Manual)

NOTE:  Unless specified, these sections are not applicable in a hospital setting.  80.6.1 - Definitions  (Rev. 94, Issued: 08- 29-08, Effective: 01- 01-03, Implementation: 09- 30-08)  Diagnostic Test   A diagnostic test includes all diagnostic x -ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary.   Treating Physician   A treating physician is a physician, as defined in 1861(r) of the Social Security Act (the Act), 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 beneficiarys specific medical problem.   A radiologist performing a therapeutic interventional procedure is considered a treating physician.  A radiologist performing a diagnostic interventional or diagnostic procedure is not considered a treating physician.  Treating Practitioner   A treating practitioner is a nurse practitioner, clinical nurse specialist, or physician assistant, as defined in 1861(s)(2)(K) of the Act, who furnishes, pursuant to State law, a consultation or treats a beneficiary for a specific medical problem, and who uses the result of a diagnostic test in the management of the beneficiarys specific medical problem.   Testing Facility   A testing facility is a Medicare provider or supplier that furnishes diagnostic tests.  A testing facility may include a physician or a group of physicians (e.g., radiologist, pathologist), a laboratory, or an independent diagnostic testing facility (IDT F).  Order   An order is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary.  The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the in itial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y).  An order may be delivered via the following forms of communication:    A written document signed by the treating physician/practitioner, which is hand- delivered, mailed, or faxed to the testing facility; NOTE:   No signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services;    A telephone call by the treating physician/practitioner or his/her office to the testing facility; and    An electronic mail by the treating physician/practitioner or his/her office to the testing facility.   If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiarys medical records.  While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed.   80.6.2 - Interpreting Physician Determines a Different Diagnostic Test is Appropriate  (Rev. 80; Issued:  01- 11-08; Effective:  01 -01-03; Implementation:  11 -19-07)  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 diagnost ic 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 CT scan because of the clinical indication), the interpreting physician/testing facility ma y 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 tes t.  80.6.3 - Rules for Testing Facility to Furnish Additional Tests  (Rev. 80; Issued:  01- 11-08; Effective:  01 -01-03; Implementation:  11 -19-07)  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 criter ia 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; and    The interpreting physician at the testing facility documents in his/her report why additional testing was done.   EXAMPLE:   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.  80.6.4 - Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests  (Rev. 80; Issued:  01- 11-08; Effective:  01 -01-03; Implementation:  11 -19-07)  The following applies to an interpreting physician of a testing facility who furnishes a diagnostic test to a beneficiary who is not a hospital inpatient or outpatient.  The interpreting physician must document accordingly in his/her report to the treating physician/practitioner.   Test Design   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, use or non- use of contrast media).   Clear Error   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, such as the patient receiving the test (e.g., x- ray of wrong foot ordered ).  Patient Condition   The interpreting physician may cancel, without notifying the treating physician/ practitioner, an order because the beneficiarys physical condition at the time of diagnostic testing will not permit performance of the test (e.g., a barium enema cannot be p erformed because of residual stool in colon on scout KUB; 170.5PA/LAT of the chest cannot be performed because the patient is unable to stand).  When an ordered diagnostic test is cancelled, any medically necessary preliminary or scout testing performed is  payable.   80.6.5 - Surgical/Cytopathology Exception  (Rev. 80; Issued:  01 -11-08; Effective:  01 -01-03; Implementation:  11 -19-07)  This exception applies to an independent laboratorys pathologist or a hospital pathologist who furnishes a pathology service to a beneficiary who is not a hospital inpatient or outpatient, and where the treating physician/practitioner does not specificall y request additional tests the pathologist may need to perform.  When a surgical or cytopathology specimen is sent to the pathology laboratory, it typically comes in a labeled container with a requisition form that reveals the patient demographics, the nam e of the physician/practitioner, and a clinical impression and/or brief history.  There is no specific order from the surgeon or the treating physician/practitioner for a certain type of pathology service.  While the pathologist will generally perform some  type of examination or interpretation on the cells or tissue, there may be additional tests, such as special stains, that the pathologist may need to perform, even though they have not been specifically requested by the treating physician/practitioner.  T he pathologist may perform such additional tests under the following circumstances:    These services are medically necessary so that a complete and accurate diagnosis can be reported to the treating physician/practitioner;    The results of the tests are communicated to and are used by the treating physician/practitioner in the treatment of the beneficiary; and    The pathologist documents in his/her report why additional testing was done.  EXAMPLE:   A lung biopsy is sent by the surgeon to the pathology department, and the pathologist finds a granuloma which is suspicious for tuberculosis.  The pathologist cultures the granuloma, sends it to bacteriology, and requests smears for acid fast bacilli (tube rculosis).  The pathologist is expected to determine the need for these studies so that the surgical pathology examination and interpretation can be completed and the definitive diagnosis reported to the treating physician for use in treating the beneficia ry.  90 - X-Ray, Radium, and Radioactive Isotope Therapy  (Rev. 1, 10- 01-03) B3-2075  These services also include materials and services of technicians.   X-ray, radium, and radioactive isotope therapy furnished in a nonprovider facility require direct personal supervision of a physician.  The physician need not be in the same room, but must be in the area and immediately available to provide assistance and direction throughout the time the procedure is being performed.  This level of physician involvement does not represent a physicians service and cannot be billed as a Part B service.  The physician would have to furnish a reasonable and necessary professi onal service as defined in 30 of this chapter, in order for the physicians activity to be covered.  However, effective for radiation therapy services furnished on or after April 1, 1989, radiologists weekly treatment management services are covered.   A separate charge for the services of a physicist is not recognized unless such services are covered under the incident to provision ( 60.1 of this chapter) or the services are included as part of a technical component service billed by a freestanding radiation therapy center.  The incident to provision may also be extended to include all necessary and appropriate services supplied by a radiation physicist assisting a radiologist when the physicist is in the physicians employ and working under his or her direct supervision.  100 - Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations  (Rev. 1, 10-01-03) B3-2079, A3-3110.3, HO-228.3,   Surgical dressings are limited to primary and secondary dressings required for the treatment of a wound caused by, or treated by, a surgical procedure that has been performed by a physician or other health care professional to the extent permissible under State law.  In addition, surgical dressings required after debridement of a wound are also covered, irrespective of the type of debridement, as long as the debridement was reasonable and necessary and was performed by a health care professional acting within the scope of his/her legal authority when performing this function.  Surgical dressings are covered for as long as they are medically necessary.   Primary dressings are therapeutic or protective coverings applied directly to wounds or lesions either on the skin or caused by an opening to the skin.  Secondary dressing materials that serve a therapeutic or protective function and that are needed to sec ure a primary dressing are also covered.  Items such as adhesive tape, roll gauze, bandages, and disposable compression material are examples of secondary dressings.  Elastic stockings, support hose, foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands are examples of items that are not ordinarily covered as surgical dressings.  Some items, such as transparent film, may be used as a primary or secondary dressing.  If a physician, certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist applies surgical dressings as part of a professional service that is billed to Medicare, the surgical dressings are considered incident to the professional services of the health care practitioner.  (See 60.1, 180, 190, 200, and 210 .)  When surgical dressings are not covered incident to the services of a health care practitioner and are obtained by the patient from a supplier (e.g., a drugstore, physician, or other health care practitioner that qualifies as a supplier) on an order from a physician or other health care professional authorized under State law or regulation to make such an order, the surgical dressings are covered separately under Part B.   Splints and casts, and other devices used for reductions of fractures and dislocations are covered under Part B of Medicare.  This includes dental splints.  110 - Durable Medical Equipment - General  (Rev. 1, 10-01-03) B3-2100, A3-3113, HO-235, HHA-220  Expenses incurred by a beneficiary for the rental or purchases of durable medical equipment (DME) are reimbursable if the following three requirements are met:    The equipment meets the definition of DME (110.1 );   The equipment is necessary and reasonable for the treatment of the patients illness or injury or to improve the functioning of his or her malformed body member (110.1); and   The equipment is used in the patients home.