Some suppliers that perform diagnostic tests, other than clinical laboratory or pathology test, are required to enroll as an Independent Diagnostic Testing Facility (IDTF). Not all suppliers that perform these diagnostic tests are required to enroll as an IDTF. Generally, entities can bill for the technical component of the diagnostic tests without an IDTF enrollment if it has the following characteristics:
- A physician practice that is owned, directly or indirectly, by one or more physicians or by a hospital;
- A facility that primarily bills for physician services and not for diagnostic tests;
- A facility that furnishes diagnostic tests primarily to patients whose medical conditions are being treated or managed on an ongoing basis by one or more physicians in the practice;
- The diagnostic tests are performed and interpreted at the same location where the practice physicians also treat patients for their medical conditions.
However, if a substantial portion of the facility’s business involves the performance of diagnostic tests, the diagnostic testing services may be a sufficient separate business to require enrollment as an IDTF. In that case, the physician or physician group practice can continue to be enrolled as a physician or physician group practice but are also required to enroll as an IDTF. The physician or group can bill for professional fees and the diagnostic tests they perform on their patients using their billing number. Therefore, the practice must bill as an IDTF for diagnostic tests furnished to Medicare beneficiaries who are not regular patients of the physician or group practice.
Recently, we have received numerous questions regarding Independent Diagnostic Testing Facilities and since the Centers for Medicare & Medicaid Services (CMS) has implemented several changes, the following information is being shared with the provider community as an educational effort.
CFR 42 § 410.33 provided for the implementation of the new designation of Independent Diagnostic Testing Facilities (IDTF) to replace the provider category of Independent Physiological Laboratory (IPL) effective July 1, 1998. The IDTF designation is described as fixed locations, mobile entities, and individual non-physician practitioners. Medicare has previously published this information in the Medicare Focus, Medicare Fee Schedule Fact Sheet, and Medicare Special Bulletins.
The Carrier will determine that all IDTF applicants meet the IDTF standards as required by CMS prior to enrollment and granting an IDTF billing number. The determination will be based upon review of the following: (1) the applicant’s entire CMS 855, including the Attachment 2 data specific to IDTFs; (2) the results of the mandatory site visit; and (3) any additional, relevant documentation obtained by the carrier.
An IDTF must have one or more supervising physicians who are responsible for the direct and ongoing oversight of the quality of the testing performed, the proper operation and calibration of equipment used to perform tests, and the qualifications of non-physician IDTF personnel who use the equipment. Not every supervising physician has to be responsible for all of these functions. One supervising physician could be responsible for operation and calibration of equipment, while other physicians are responsible for test supervision and the qualifications of non-physician personnel.
The basic requirement is that all the supervising physician functions be properly met at each location, regardless of the number of physicians involved. This is particularly applicable to mobile IDTF units that are allowed to use different supervising physicians at differing locations. They may have a different physician supervise the test at each location. The physicians have to meet only the proficiency standards for the tests they are supervising. The carrier will use its discretion to determine if the supervising physician(s) meet the proficiency standards stated in 42 C.F.R. §410.33(b)(2). Supervising physicians do not have to be employees of the IDTF. They can be contracted physicians for each location serviced by an IDTF.
As defined in 42CFR410.33(b)(2), The supervising physician must evidence proficiency in the performance and interpretation of each type of diagnostic procedure performed by the IDTF. The proficiency may be documented by certification in specific medical specialties or subspecialties or by criteria established by the carrier for the service area in which the IDTF is located. In the case of a procedure requiring the direct or personal supervision of a physician as set forth in Sec. 410.32(b)(3)(ii) or (b)(3)(iii), the supervising physician must personally furnish this level of supervision…
The law does not speak to this being a “supervision of the administration of contrast media”, but rather, is a distinction drawn as to the degree of difficulty in the performance and the interpretation of the procedure. This degree of difficulty is assigned to the levels of supervision and the warranted payment of the professional component of the CPT code.
Section 410.32(b) of the Code of Federal Regulation, as adopted in the Medicare physician fee schedule final rule of October 31, 1997, requires that diagnostic tests covered under § 1861(s)(3) of the Social Security Act and payable under the physician fee schedule must be performed under the appropriate level of supervision by a physician as defined in § 1861 ® of the Social Security Act. Further, the preamble to the final rule of October 31, 1997 assigned a level of physician supervision to most diagnostic tests payable under the physician fee schedule and was implemented January 28, 1998. The list provides the required level of physician supervision for each test performed.
As defined by the regulation, these levels of physician supervision are assigned to each Current Procedural Terminology Code (CPT) under the provisions of 42 CFR 410.32(b) and must be met in order to be paid by Medicare.
The role of the Supervising Physician in an IDTF clearly precludes any physician who does not have the specialized training required for the specific procedure from “supervising” the testing without documentation of additional training in this exclusive area of proficiency. A statement of “considerable experience…related to imaging…” does not suffice as evidence of proficiency in the performance of such testing.
Recently the Carrier Medical Directors have looked at the question of radiology residents as supervising physicians in an IDTF. It was their decision that a radiology resident does not meet the requirements of a supervising physician for an IDTF since radiology residents are in training and are not qualified to be supervising or interpreting physicians for any IDTF.
Also, the IDTF must maintain documentation of sufficient physician resources during all hours of operations to assure that the required physician supervision is furnished. The carrier may ask for written procedures from the IDTF describing how this is being met.
Each non-physician, often referred to as technicians, who performs the diagnostic tests must be state licensed or certified by a recognized national credentialing body. All technicians must meet the standard of a state license or certification or a national credentialing body. The only exception to this is when a Medicare payable diagnostic test is not subject to state license or certification of the technician performing the test, and no generally accepted national credentialing body exists. In that instance, the technician should be listed and the IDTF should submit as an attachment any educational/credentialing and/or experience that the person has and fully justify why the individual should be considered qualified to perform the test(s) cited. The carrier will determine whether the technician is qualified to perform the diagnostic tests the IDTF is performing.
All enrolling IDTFs must meet the technician licensing or credentialing requirements at the time of their enrollment. Carriers may not grant temporary exemptions from licensing and certification requirements.
NOTE: The IDTF is prohibited from billing for tests that are performed by technicians who have not been approved through the Medicare application process. The IDTF should hold all claims for services that are performed by technicians whose names and qualifications have not yet been approved by Medicare.
In an effort to assist providers in determining the requirements of supervising physicians and technologists, we are including the current list of procedure codes performed in IDTFs, the levels of supervision required for each test and the qualification for technicians involved in the performance of specific diagnostic tests.
Medicare Table of IDTF Diagnostic Tests
With Level of Supervision Requirements, and Supervising Physician and Technician Qualification Requirements
Lists procedure codes and short descriptors for diagnostic tests performed in IDTFs.
The short descriptors for diagnostic tests performed in IDTFs.
Lists the level of physician supervision required for each diagnostic test. The levels are as follows:
- 1= General supervision of a physician
- 2= Direct supervision of a physician
- 3= Personal supervision of a physician
- 4= Physician supervision does not apply if performed by a qualified independent psychologist or a clinical psychologist; otherwise general supervision of a physician is required
- 5= Physician supervision does not apply if performed by a qualified audiologist; otherwise general supervision of a physician is required
- 6= Must be personally performed by a physician or by a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical specialist and is permitted to provide the service under State law.
- 66= May be performed by a physician or a physical therapist with ABPTS certification and certification in this specific procedure.
- 6A= Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may supervise another PT, but only the PT with ABPTS certification may bill.
- 21= Procedure may be performed by a technician with certification under general supervision of a physician; otherwise must be performed under the direct supervision of a physician.
- 7A= Must be personally performed by a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) or by a PT without certification under direct supervision of a physician, or by a technician with certification under general supervision; in addition, the PT with ABPTS certification may supervise another PT, but only the PT with ABPTS certification may bill.
- 9= PC/TC Indicator Not Applicable- concept of a professional/technical component does not apply.
Lists the qualifications that the physician supervising the specific test
must possess. Medicare requires that physicians supervising diagnostic tests in
an IDTF provide evidence of proficiency in the performance and interpretation
of the tests that they supervise. If a physician does not possess the exact
qualifications listed but believes that he/she is qualified to supervise a
specific test, the Carrier will consider information that is submitted
documenting specific formal training and experience related to the procedure in
- ABMS = American Board of Medical Specialties
- ABSM = American Board of Sleep Medicine
Lists the required qualifications for technicians involved in the performance of specific diagnostic tests. Abbreviations related to technician qualifications are as follows:
- AAET = American Association of Electrodiagnostic Technologists
- ABRET = American Board of EEG and Evoked Potential Technologists
- ARRT = American Registry of Radiologic Technologists (R = Radiography, N = Nuclear Medicine, CT = Computed Tomography MR = Magnetic Resonance, BD = Bone Densitometry, S = Sonography)
- ARDMS = American Registry of Diagnostic Medical Sonographers
- BRPT = Board of Registered Polysomnographic Technologists
- CRT = Certified Respiratory Therapist
- CRT-N = Certified Radiologic Technologist- Nuclear Medicine
- JCAHPO = Joint Commission on Allied Health Personnel in Ophthalmology
- NBRC = National Board for Respiratory Care
- NMTCB = Certified Nuclear Medicine Technologist
- R. EEG T. = Registered EEG Technologist
- RPFT = Registered Pulmonary Function Tech
- RPSGT = Registered Polysomnographic Technologist
- RRT = Registered Respiratory Therapist Certified in relevant area = certified in the performance of tests of type described by HCPCS Code