LCD/NCD Portal

NCD70.5 HOSPITAL AND SKILLED NURSING FACILITY ADMISSION DIAGNOSTIC PROCEDURES

 

 

Effective Date of this Version

9/1/1979

 

 

Benefit Category

 

• Diagnostic Laboratory Tests.

• Diagnostic Tests (other).

• Diagnostic X-Ray Tests.

• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

 

 

Indications and Limitations of Coverage

 

• These instructions clarify the application of the reasonable and necessary payment exclusion to diagnostic procedures, such as chest X-rays, urinalysis, etc. provided to patients upon admission to a hospital or skilled nursing facility.

• The major factors which support a determination that a diagnostic procedure performed as part of the admitting procedure to a hospital or skilled nursing facility is reasonable and necessary are:

o The test is specifically ordered by the admitting physician (or a hospital or skilled nursing facility staff physician having responsibility for the patient where there is no admitting physician):

 It is NOT furnished under the standing orders of a physician for his patients.

o The test is medically necessary for the diagnosis or treatment of the individual patient's condition.

o The test does not unnecessarily duplicate the same test performed on an outpatient basis prior to admission or performed in connection with a recent hospital or skilled nursing facility admission.

• Where you have not already done so, consult with QIOs to obtain information gathered by the QIOs on a sample basis as to whether X-rays and diagnostic tests are being specifically ordered as described.

 

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