Hospital and Skilled Nursing Facility Admission Diagnostic

70.5 - Hospital and Skilled Nursing Facility Admission Diagnostic Procedures (Rev. 173, Issued: 09-04-14, Effective: Upon Implementation: of ICD-10, Implementation: Upon Implementation of ICD-10) These instructions describe 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: A. 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): i.e., it is not furnished under the standing orders of a physician for his patients; B. The test is medically necessary for the diagnosis or treatment of the individual patient’s condition; and C. 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 the A/B MAC has not already done so, consult with the Quality Improvement Organizations (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 under subsection (A).