How to properly perform and bill medically necessary testing

In an ideal world, you would anticipate your provider’s needs for patient diagnostic testing to maximize clinic flow. However, Medicare rules for billing medically necessary testing must be followed, which means a provider’s order reflecting medical necessity must be placed before a diagnostic test is performed.

A potential workaround is to ask Medicare patients to pay for screening or protocol testing by signing an Advanced Beneficiary Notice of Noncoverage (ABN), but that’s not ideal. Regularly not allowing patients to use their insurance does not serve them well. Additionally, Medicare frowns on routine ABN applications for what should be medically necessary services.

Let’s review the compliance workflow steps needed to bill medically necessary diagnostic tests while increasing clinic efficiency.

Establish a procedure for new patients.

When you and other technicians anticipate the provider may want a medically necessary test on a new patient, it makes sense to hit pause on the patient workup so the provider can place a test order. A proper workflow can lead to efficiency. For example, the technician calls in the physician, who reviews the workup and places the test order, so the technician may perform the test.

In absence of a similar workflow, the provider usually ends up seeing the patient twice in a more drawn-out fashion or orders the test for the next visit.

Streamline the process for established patients.

As mentioned above, diagnostic tests must have a physician’s order before being performed. When documenting orders for established patients, physicians should try to anticipate and order testing for the patient’s next visit based on today’s examination.

If you’re scribing, enter that advance order at the current visit. Include testing details such as the diagnosis and reason for the test, type of test and any specifics (ie, VF 24-2, OCT Mac) and which eye is to be tested. This upfront work prevents the provider from having to see the patient twice at the next visit to place the order.

Use electronic health record (EHR) tools.

Every certified EHR has an order module of some type. Learn how it works, and use it to increase practice efficiency and compliance. You should be able to create test order sets for certain disease states. This will allow order details to be charted quickly when chosen by the provider.

Using an order module should also help ensure all performed tests are interpreted and reported to the patient. For example, you may be able to set the system up to prevent billing until an interpretation is complete.

Create separate, clear interpretations and reports.

Most ophthalmic diagnostic tests require an interpretation and report. Since providers are paid separately for testing, ensure the components of the interpretation and report are separately identified within same-day visits and easy to identify in chart documentation.

The interpretation and report should include the test date, indication for the test, who performed the test, testing reliability, findings, resulting diagnosis, impact on the patient’s care and next steps, and the provider’s signature. Of those items, the test results’ impact on care is a common missing interpretation component. That element is important because documentation must show the added value — beyond the visit examination — for the test being billed.

Avoid single phrases like “confirms clinical findings.” Other interpretations to avoid are “normal” or “within normal limits.” While these phrases may be truthful, they do not reflect the added value of the test. Be sure to document detailed findings and what was expected but not found.

Timing is everything.

Remember, Medicare pays for diagnostic tests based on orders that document medical necessity. Therefore, test orders must be in place prior to testing, with protocol-driven or screening tests not covered by Medicare.

Ensure reimbursement compliance and efficiency with testing by keeping the test order and the order of testing top of mind. OP