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Clarification of Ordering of Diagnostic Tests Rule and ICD-9 Coding Guidelines Issued by DMS

The American College of Radiology (ACR) has been successful in its efforts to obtain clarification from the Centers for Medicare and Medicaid Services (CMS – formerly known as HCFA) on the "ordering of diagnostic tests rule" (42 CFR 410.32) and "ICD-9 coding for diagnostic tests." These two issues have been variably interpreted across the country by Carrier Medical Directors, compliance officers and consultants, resulting in significant difficulty for radiologists and inconvenience for Medicare beneficiaries. Last week CMS issued program memoranda (PMs) on both issues to all its Medicare carriers. The PM on the "Ordering of Diagnostic Tests Rule" is to be implemented "upon issuance" (released 9/26/01), but does not affect previously adjudicated claims. The ICD-9 coding PM is effective January 1, 2002. To view these PMs, go to:

• Ordering of Diagnostic Tests - Program Memorandum 9/26/01 - PDF Format

            (http://www.acr.org/departments/econ/medicare/order_test.pdf)

• ICD-9-CM Coding for Diagnostic Tests

In response to the ACR's repeated requests and extensive work by the economics and health policy department, CMS has clarified to all Carrier Medical Directors that:

• the "ordering of diagnostic tests rule" does not apply to hospital inpatients or outpatients;
• an order from the referring physician to the radiologist in a free-standing setting (not hospital owned), other than an Independent Diagnostic Testing Facility (IDTF), does not have to be in writing;
• additional testing may be done by the radiologist 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);
• radiologists may code the findings from the radiology examination as a primary diagnosis on the HCFA claim form.

The ACR has worked diligently with CMS for the last two years to articulate that the widespread misinterpretation of the "ordering of diagnostic tests rule" by many of the carrier medical directors (CMDs), auditors, and hospital compliance officers has been detrimental to the practice of radiology and has limited radiologists' ability to promote appropriate and efficient imaging evaluations of Medicare beneficiaries. This hard work has produced a clarification that the ACR believes, with education and communication, will remedy most misunderstandings.

Please see the economics column in the November 2001 ACR Bulletin for a more detailed description of the clarification by CMS on these PMs and revisions to the "supervision rule." You may obtain copies of the program memoranda from the ACR's economics and health policy department at 800-227-5463, ext. 4584 or by going to the ACR Web site as listed above.

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