NYSRS Medical Insurance and Compensation Committee Report

 April 26, 2003

Arthur J. Segal, M.D., F.A,C.R., Chairman

                                                                              MEDICARE UPDATE


CODING FOR CT SCANS:


Effective Date:   03/27/2003
Change:
 

The list of ICD-9-CM codes that support medical necessity have been removed from this policy with the exception of those ICD-9-CM codes for CT scan of the TMJ (billed with         CPT code 76497).


CPT code 76497 and HC PCS code G0288, both effective 1/1/2003, have been added to the policy.


CPT code 76070 and HC PCS codes GO131 and G 0132 have been removed as they are covered under our policy #YRAD11 (Bone Mass Measurements).


BREAKING NEWS - ACR Successful in Expanding MRA Coverage!

"The American College of Radiology has successfully obtained expanded coverage of magnetic resonance angiography procedures to include the renal and pelvic arteries. Effective July 1, the Centers for Medicare and Medicaid Services will cover (1) MRA to evaluate renal arteries in patients without a damaged aorta, (2) MRA to evaluate pelvic arteries in patients without a damaged aorta, and (3) catheter angiography in addition to MRA, when clinically warranted."

CODING FOR MRI & MRA Reconstruction:

Three-dimensional (3-D) reconstruction is covered with magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) for the same

diagnoses as listed in the Computerized Axial Tomography Policy #RD003E02. However, code 76375 should not be used for "routine" acquisition of MR images in conventional planes (axial, sagittal, coronal). It should be used when non-routine reconstructions and/or 3-D imaging is required. Supportive clinical information should be contained in the medical record.

76375 Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction of computerized axial tomography, magnetic resonance imaging, or other tomographic modality

Ordering Diagnostic Tests:

The following information is a revision to information previously published on page 20 of the December 2001 Medicare B Hotline Bulletin. This revision broadens the instructions to include additional physicians as interpreting physicians. These changes were implemented February 24, 2003.

A. Definitions

l. A "diagnostic test” includes all diagnostic x-ray tests, all diagnostic laboratory tests, and other diagnostic tests furnished to a beneficiary.

2. 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 beneficiary's specific medical problem.

Note: 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.

3. 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, beneficiary's specific medic al problem.

4. 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 (IDTF).

5. An "order" is a communication from the treating physician/practitioner requesting that a diagnostic test be perform ed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial 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 include the following forms of communication:

    a. 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 physician fee schedule or for physician pathology services.

    b. A telephone call by the treating physician/practitioner or his/her office to the testing facility; and

    c. An electronic mai1 by the treating physician/practitioner or his/her office to the testing facility.

    Note:
    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 beneficiary's medical records.

B. Treating Physician/Practitioner Ordering of Diagnostic Tests

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 which require performance of sequential tests.

C. Different 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 c1inically 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 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.

D. Additional Diagnostic 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:

    1. The testing center performs the diagnostic test ordered by the treating physician/practitioner;

    2. 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;

    3. Delaying the performance of the additional diagnostic test would have an adverse effect on the care of the beneficiary;

    4. The result of the test is communicated to and is used by the treating
physician/practitioner in the treatment of the beneficiary; and

    5. The interpreting physician at the testing facility documents in his/her 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.

E. Interpreting Physician Exception

This exception 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.

    1. 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).

    2. 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 reason able lay person, such as the patient receiving the test (e.g., x-ray of wrong foot ordered).

3. Patient Condition.- The interpreting physician may cancel, without notifying the treating physician/practitioner, an order because the beneficiary's physical condition at the time of diagnostic testing will not permit performance of the test (e.g., a barium enema cannot
be performed because of residual stool in colon on scout KUB; PA/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.

F. Surgical/Cytology Exception

This exception applies to an independent laboratory's 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 specifically 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 name 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. The pathologist may perform such additional tests under the following circumstances:

    1. These services are medically necessary so that a complete and accurate diagnosis can be reported to the treating physician/practitioner;

    2. The results of the tests are communicated to and are used by the treating physician/practitioner in the treatment of the beneficiary; and

    3. 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 (tuberculosis). 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 beneficiary. New Medicare Fee.

Home Page Information:

http://www.ghimedicare.com/

http://www.umd.nycpic.com/

http://www.gao.qov

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Respectfully submitted,


Arthur J. Segal, M.D., F.A.C.R.
Chairman, Medical Insurance and Compensation Committee