E. Hospital and skilled nursing facility admission diagnostic procedures

These instructions clarify 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:

1. 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 their patients;

2. The test is medically necessary for the diagnosis or treatment of the individual patient's condition; and

3. The test does not unnecessarily duplicate a test performed on an outpatient basis prior to admission or performed in connection with a recent admission.

Intermediaries consult with PSRO's to obtain information they gathered on a sample basis as to whether X-rays and diagnostic tests are specifically ordered as described in 1. above.