Instruction to Determine the Reason for the Test

As specified in the Balanced Budget Act (BBA), referring physicians are required to provide diagnostic information to the testing entity at the time the test is ordered.

On the rare occasion when the interpreting physician does not have diagnostic information as to the reason for the test and the referring physician is unavailable to provide such information, it is appropriate to obtain the information directly from the patient or the patient’s medical record if it is available. However, an attempt should be made to confirm any information obtained from the patient by contacting the referring physician.

Example: A patient is referred to a radiologist for a gastrograffin enema to rule out appendicitis. However, the referring physician does not provide the reason for the referral and is unavailable at the time of the study. The patient is queried and indicates that he saw the physician for abdominal pain and was referred to rule out appendicitis. The radiologist performs the X-ray, and the results are normal. The radiologist should report the abdominal pain as the primary diagnosis.

In the event the physician’s interpretation of the test result is not clear or ambiguously stated in the patient's medical record, contact either the attending physician or the physician who performed the test for clarification. This may result in the reporting of symptoms or a confirmed diagnosis.

If the test (i.e., lab test) has been performed and the results are back but the patient's physician has not yet reviewed them to make a diagnosis, or there is no physician interpretation, then code the symptom or the diagnosis provided by the referring physician.

In the event the individual responsible for reporting the codes for the testing facility or the physician's office does not have the report of the physician interpretation at the time of billing, that individual should code what they know at the time of billing.

Sometimes reports of the physician's interpretation of diagnostic tests may not be available until several days later, which could result in delay of billing. In such instances, the individual responsible for reporting the codes for the testing facility or the physician's office should code based on the information/reports available to them or what they know at the time of billing.