CMS Relaxes Rules on Ordering and Documenting Imaging Services

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Thomas W. GreesonPaul PittsTwo years ago, CMS published an interim final rule¹ (with a comment period) implementing several changes to the Medicare and Medicaid programs mandated by the Patient Protection and Affordable Care Act. The interim final rule of May 2010 established new rules on obtaining and maintaining written orders for imaging services, as well as orders or referrals for durable medical equipment, home health care, and laboratory services. The interim final rule required the legal name and national provider identifier (NPI) of the ordering physician or practitioner on the claim. In addition, the ordering and furnishing providers were each required to maintain documentation of the written order for seven years.

The ACR®, the RBMA, and other radiology organizations jointly submitted comments to CMS regarding specific aspects of the interim final rule. Now, CMS has signaled its acceptance of several major changes requested by the radiology organizations. In a final rule 2 published April 27, 2012, CMS has revised the ordering and documentation requirements for imaging services in several ways that are favorable to the radiology community.

The most significant change is that the rule now requires only the ordering provider and the technical-component supplier to maintain documentation of the order or referral for seven years. Radiologists (or radiology groups) providing the professional component are not required to maintain documentation of orders unless they also furnish the technical component (as in radiologist-owned imaging centers).

In a big win for imaging providers, the final rule also relaxes the requirements covering who may order an imaging service. While the rule still requires ordering physicians and other eligible professionals to be enrolled in the Medicare program (or to maintain a valid opt-out record), the ordering provider is not required to be in registered in the Medicare provider enrollment, chain, and ownership system (PECOS) in order for Medicare to pay a claim for imaging services. This change addresses those circumstances where the ordering physician is enrolled in Medicare, but not yet registered in PECOS.

In the preamble to the final rule, CMS states that these conditions apply only to imaging services furnished by IDTFs, mammography centers, portable imaging facilities, and radiation-therapy centers. The final rule does not apply to imaging services provided in the hospital outpatient setting. Unfortunately, CMS does not make this distinction in the language of the rule itself, but only in the guidance published with the final rule. This CMS failure to be more clear in the regulatory language might lead to confusion in the future as Medicare administrative contractors (MACs) and other agencies seek to implement these requirements.

The requirements for establishing and maintaining Medicare billing privileges (for both the ordering physician and the supplier of the ordered test) have increased significantly in recent years. These efforts, lead by Congress and CMS, are intended to root out ineligible and fraudulent claims, but they apply broadly to all providers and suppliers treating Medicare beneficiaries.

As a result, radiologists and imaging centers are increasingly subject to complex audits of their Medicare claims. Given the heightened regulatory authority of CMS and its auditors, now is a good time for radiology practices and imaging suppliers to review their Medicare enrollment and revalidation procedures, claims for Medicare services, and policies for retaining appropriate documentation.

Documentation Requirements

The final rule requires imaging providers and suppliers to maintain documentation of written orders for seven years from the date of service, including the NPI and legal name of the ordering physician or eligible nonphysician practitioner. In addition, the final rule requires ordering providers and suppliers to maintain documentation for seven years from the date of service.

In another favorable change, CMS clarified that documentation of the order must be retained from the date of service, rather than from the date of the order, as originally stated in the May 2010 interim final rule. This change makes the documentation requirement consistent for both ordering and furnishing providers.

The documentation of the order or referral must be supplied to CMS or the Medicare contractor upon request. Failure to comply with the documentation requirements could result in a one-year