Documentation needed if non-hospital imaging center does an exam not ordered by the patient’s treating physician

Q.

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? 

A.

 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, all of the following criteria must be met:

• 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.