It is important to recognize that tests have four principal uses in clinical settings:

Screening: Screening refers to the use of a test to detect either asymptomatic disease or a predisposition to disease (i.e., a risk factor such as elevated blood pressure or high blood cholesterol). Typically, the pre-test probability of disease (i.e., the prevalence or probability of disease in the population to be screened) is very low in such individuals. The purpose of screening is either to take action to prevent disease by modifying a risk factor, or to detect and treat disease early. In both cases, screening is presumed to be advantageous because early treatment of disease, or modification of a risk factor, improves health outcomes.

Diagnosis : a test is used to make a diagnosis when symptoms, abnormalities on physical examination, or other evidence suggests but does not prove that a disease is present. Making a correct diagnosis improves health outcomes by leading to better clinical decisions about further testing and/or treatment.

Staging : a test is used to stage a disease when the diagnosis is known but the extent of disease is not known. Staging is particularly important when stage of disease, as well as the diagnosis itself, influences management. For example, an early stage cancer might be treated surgically, while the same cancer at a more advanced stage might be treated with chemotherapy alone.

Monitoring : In a patient known to have a health condition, a test is used to monitor the disease course or the effect of therapy. A monitoring test helps to evaluate the success of treatment and the need for additional testing or treatment.

Supervision Requirements for Diagnostic Testing:

• General Supervision : In order to bill for the interpretation of the test: The procedure is furnished under the physician’s overall direction and control but that the physician’s presence is not required during the performance of the test. The physician remains responsible for the physician personnel performing the procedure. If a resident prepares and signs the interpretation, the teaching physician must indicate that he or she has personally reviewed the image and the resident’s interpretation and either agrees or with it or edits the findings. A countersignature alone of the resident’s interpretation by the teaching physician is not acceptable documentation.
• Direct Supervision : In an office setting, the physician must be present in the office to be immediately available to furnish assistance and direction (but, doesn’t have to be physically present during the test).
• Personal Supervision : The physician must be in attendance in the room during the performance of the procedure. If the teaching physician’s signature is the only signature on the interpretation, this can be assumed that he or she personally reviewed the image and performed the interpretation.

Coverage for Diagnostic Services:

• Routine services for screening with only “rule out” diagnoses are not covered. However, routine services with “rule out” diagnosis accompanied by symptoms, patient’s complaints, or other diagnosis are covered subject to normal medical necessity guidelines.
• Non-routine tests performed to “rule out” suspect conditions are covered subject to normal medical necessity guidelines.
• Pre-operative tests, chest x-rays, and EKGs performed prior to schedule surgery are also subject to medical necessity guidelines.

Coverage for Surgical Procedures:

• Services performed in connection with research or experimental studies are generally excluded from payment. However, Category B clinical trials, investigational and not experimental, may be reimbursable.
• Adverse events secondary to experimental treatment are covered.