Medicare Coverage of Diagnostic Radiology Services
Medicare Part B (Medical Insurance) covers medically necessary clinical diagnostic laboratory tests, when your doctor or practitioner orders them. These tests are done to help your doctor diagnose or rule out a suspected illness or condition.
Diagnostic non-laboratory tests
Part B covers diagnostic non-laboratory tests when your doctor or other health care provider orders them as part of treating a medical problem. Examples of diagnostic non-laboratory tests include CT scans, MRIs, EKGs, X-rays, and PET scans. These tests are done to help your doctor diagnose or rule out a suspected illness or condition.
All people with Part B are covered.
Diagnostic laboratory tests
You generally pay nothing for Medicare-covered diagnostic laboratory tests.
Diagnostic non-laboratory tests
You pay 20% of the HYPERLINK "https://www.medicare.gov/coverage/diagnostic-tests.html#1378" \o "In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference." Medicare-approved amount for covered diagnostic non-laboratory tests and X-rays done in a doctor's office or in an independent testing facility. The Part B HYPERLINK "https://www.medicare.gov/coverage/diagnostic-tests.html#1306" \o "The amount you must pay for health care or prescriptions before Original Medicare, your prescription drug plan, or your other insurance begins to pay." deductible applies.
You pay a HYPERLINK "https://www.medicare.gov/coverage/diagnostic-tests.html#1297" \o " An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor's visit, hospital outpatient visit, or prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor's visit or prescription drug. " copayment for diagnostic non-laboratory tests and X-rays done in the hospital outpatient setting.
There are three core requirements for a radiology test to be covered under Medicare. The test must be properly ordered by a treating physician (with limited exceptions), the test must be performed by an authorized supplier, and the test must be performed under the proper level of physician supervision. This article will briefly cover all three of the prerequisites to coverage of diagnostic radiology tests. The requirements described in this article apply to outpatient tests.
Who may order diagnostic radiology tests?
The Medicare reimbursement rules have strict standards for determining who is authorized to order a diagnostic radiology test. The rules are different depending upon whether the provider is located in a hospital or in a non-hospital setting such as an independent diagnostic testing facility or physician’s office.
Generally, in a non-hospital setting, a diagnostic radiology test must be ordered by the treating physician. The treating physician rule is located in the Medicare regulations and requires that the diagnostic test be ordered by the physician (or in certain circumstances a non-physician practitioner) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results of the diagnostic radiology test in the management of the patient’s medical problem. Generally, the radiologist performing the test is not permitted to order a diagnostic radiology test.
A radiologist is authorized to order a diagnostic mammography test based upon the results of an initial screening examination. Where the treating physician cannot be reached and this is documented in the patient’s chart, the testing facility may furnish additional diagnostic tests if the interpreting radiologist at the testing facility documents that there are abnormal results with the test originally ordered by the treating physician and that an additional test is medically necessary. In order to rely on this exception, the fact that the treating physician was not available and that additional tests were medically necessary should be well documented in the chart. This exception requires the results of the test to be communicated to the treating physician and used by the treating physician in treating the patient’s medical condition.
Where medically appropriate, the interpreting radiologist is also permitted to make determinations regarding the parameters of the diagnostic test contained in the initial order from the treating physician. In cases where there is a clear and obvious error in the initial order, the interpreting physician may make appropriate modifications. The intervening physician may also cancel orders based upon the patient’s medical condition at the time of the diagnostic tests.
Except for the limited circumstances described above, the radiologist must always rely upon the order that is made by the treating physician and may not independently order diagnostic radiology tests.
Who Is Qualified to Perform the Radiology Test?
The second major requirement for the coverage of radiology services in a non-hospital setting is that only a qualified provider of the services may be reimbursed. Qualified providers include physicians, group practices of physicians, approved portable x-ray suppliers, independent diagnostic test testing facilities, nurse practitioners or clinical nurse specialists as authorized under state law, FDA certified mammography facilities, clinical psychologists for certain types of tests, qualified audiologists, pathology slide preparation facilities, clinical laboratories for certain tests and radiation therapy centers.
Level of Physician Supervision for Diagnostic Imaging Tests
The last of the major requirements for coverage of radiology services is the level of physician supervision that is required given the specific test being performed. Radiology services must be provided under at least a; general level physician supervision. Additionally, certain tests must be provided under direct or personal supervision, which require higher levels of physician presence and involvement. Failure to provide the appropriate level of physician supervision and to document the supervision in the chart will result in loss of coverage under Medicare. Any claims submitted in spite of not meeting the supervision requirements will be considered to be not reasonable or necessary by Centers for Medicare & Medicaid.
There are a few exceptions from the physician supervision requirements for certain limited types of tests. It must be kept in mind however that these exceptions are Medicare only exceptions and there may be other federal or state laws that apply to require physician supervision. Tests that are excepted from physician supervision requirements include diagnostic mammography procedures, diagnostic tests performed by a qualified audiologist and certain psychological tests. The physician is not required to be physically present in the room where the procedure is performed unless there is a need for the physician’s presence due to some problem that arises during the course of performing the test.
The highest level of physician supervision is personal supervision. Personal supervision requires a physician to actually be present in the room during the performance of the procedure. Personal supervision generally involves diagnostic tests with invasive or otherwise dangerous aspects. One significant example of a test that requires personal supervision is contrast studies.