Question:

What documentation is required if our non-hospital imaging center needs to do an exam in addition to that which was ordered by the patient’s treating physician?

Answer:

According to the Medicare Benefit Policy Manual, chapter 15, section 80.6, if a radiologist at a non-hospital location believes that an additional exam should be performed, he should attempt to reach the patient’s treating physician to get a new order. If that is not possible, all of the following criteria must be met and documented:

  • 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
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