As options for imaging entities continue to broaden and diversify, Independent Diagnostic Testing Facilities (IDTFs) are coming under frequent consideration.

In a presentation at the 2005 RBMA (Radiology Business Management Association) Fall Educational Conference in Seattle, Thomas W. Greeson, Esq, a partner with Reed Smith LLP in Virginia, discussed the requirements of IDTFs.

To qualify for Medicare coverage, Greeson said, IDTFs come under a specific set of rules that often are more restrictive than those required for radiology physician group practices. And while there is no difference in the Medicare payment mechanism between an IDTF and a physician practice, the restrictions can have an impact on the overall operating costs of the entity. In his remarks, Greeson advised that those who are considering an IDTF entity should carefully weigh those restrictions and differences.

IDTFs AND MEDICARE ENROLLMENT

Medicare defines IDTFs as suppliers of diagnostic tests that are independent of a hospital or a physician office. An IDTF may be a fixed location, a mobile entity, or an individual nonphysician practitioner.

An imaging facility that performs diagnostic testing must enroll with Medicare as an IDTF unless it meets the following criteria:

  • The facility is owned by radiologists, a hospital, or both.
  • The radiologists usually perform test interpretations at the location where the diagnostic tests are performed.
  • The facility does not usually purchase interpretations.
  • The facility ordinarily bills globally.

A facility that does meet these conditions could enroll as a radiology group practice rather than an IDTF. A hospital outpatient diagnostic facility does not have to enroll as an IDTF if it provides diagnostic testing to registered hospital outpatients directly in the hospital, in a hospital-based environment, or under arrangement. A hospital does not have to enroll an off-campus facility as an IDTF if the facility satisfies the criteria for maintaining provider-based status.

An entity that provides diagnostic testing to a hospital “under arrangement” does not have to be enrolled as an IDTF as long as the hospital bills under its provider number for the diagnostic tests.

An ambulatory surgery center also can be an IDTF if its imaging services are directly related to, and performed in conjunction with, a surgical procedure. But they may not share space and they may not provide services at the same time.

Greeson said that although Medicare payments are the same to IDTFs and radiology physician practices, Medicare tends to place more stringent conditions on IDTFs.

For example, a condition of participation is that an IDTF may perform and bill for only diagnostic testing services. An IDTF may not bill for therapeutic or interventional radiology procedures such as vascular access procedures or biopsies.

GENERAL SUPERVISION CONDITIONS

Another condition for IDTFs is the supervising physician requirement. IDTFs must provide at least one “general supervision” physician who is responsible for overall direction and quality control of the services performed in the IDTF.

According to Greeson, out of concern for the quality of services provided in IDTFs, CMS imposed regulations stating that all supervising physicians must meet a proficiency requirement.

“As the physician responsible for general supervision, you better make sure you carry out these responsibilities and in my opinion you should be paid for these services by the IDTF,” Greeson said. “You should be involved in making sure the equipment is running properly or have actually signed off on the ongoing reviews for the radiologic technologists. You should be involved in all activities relating to quality.”

IDTFs can use more than one supervising physician and employment is not required, but the supervising physician must be proficient in the performance and interpretation of tests being done at the IDTF. The IDTF must identify supervising physicians on CMS 855B (application for suppliers that will bill Medicare), and their proficiency must be documented in accordance with criteria established by the Medicare carrier.

Greeson pointed out that radiology group practices are not subject to the same proficiency requirements for supervising physicians and they are not required to identify supervising physicians on the CMS 855B.

“Ironically, if you have an imaging center that’s enrolled as a diagnostic radiology group practice, you can actually contract with a nonradiologist to perform the supervision requirements,” he said. “But if you’re enrolled as an IDTF, you are required to provide supervision for all the diagnostic testing services that are performed there, both the general and direct supervision.”

Greeson also said that IDTFs must maintain documentation showing sufficient physician supervision during all hours of operation. “When CMS performs their site visits, they are instructed to query the technologists to determine whether they know who the supervising physicians are and how they can reach them if they need them,” he said. Documentation of physician coverage is not a requirement for radiology group practices.

DIRECT SUPERVISION

Greeson said that there is also a direct supervision requirement for IDTFs, which states that the physician performing direct supervision must be present in the office suite and must be immediately available to assist if needed.

“This means you’re actually there while the services are being performed,” said Greeson. “If you are performing direct supervision for an IDTF on the third floor, and your radiology office is in the basement, are you fulfilling that requirement? My answer is: you need to be available. You are in fact in the same suite of offices and you would not have to go far to get to that patient if needed.” Physician presence in the room is not required in most cases. Supervision is required for contrast studies.

Direct supervision must be performed by a physician who meets proficiency requirements, and some Medicare carriers have said specifically that only board-certified radiologists or nuclear medicine physicians can perform these services. “They will not even permit radiology residents to supervise contrast studies in IDTFs,” he said.

Greeson said that another difference between physician practice groups and IDTFs is that physician practice groups may accept orders by phone, e-mail, or fax. For ITDFs, however, all tests must be specifically ordered in writing by the physician who is furnishing a consultation or treating a patient for a specific medical condition and who uses the results in the management of the patient’s specific medical problem. The order must specify a diagnosis. The supervising physician may not order tests unless they are a patient’s treating physician. The IDTF cannot add procedures based on internal protocols without a written order from the patient’s treating physician.

Tamara Greenleaf is a contributing writer for Decisions in Axis Imaging News.