Follow the links at this bottom of this page to view and download a PDF copy of all the content within this page. Individual Forms within the Doctor’s Kit are also available for download.
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Physicians’ Diagnostic Testing Guide
Indications and Forms
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Welcome! We are pleased to be of service to your patients and facility and look forward to working with you. In the very near future, we will be offering additional “State of the Art” care enhancing programs that are sure to benefit your patients and your practice. We are looking forward to a long-term, highly prosperous relationship.
On this page and enclosed in the downloadable packet are all the forms you will need. These forms are needed ten (10) days prior to your scheduled test date. You will find the following forms to be completed for each patient:
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Testing Schedule Form to be completely filled out for every testing date requested in the future.
Patient Information Form to be filled out on every patient tested to assist in pre-certifying the Insurance or Workers’ Compensation / PI cases. You may submit your own demographics sheet in place of our form.
Doctor Test Ordering Form to be filled out completely, signed and dated by the ordering doctor. There are two separate forms for Neurodiagnostic and Ultrasound diagnostic studies.
Green Lien Form is required for all Workers’ Compensation cases to also include the “Doctors First Report” or “PR-2”
Patient Freedom of Choice Form must be given to and signed by each patient upon prescribing a diagnostic test.
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Please take time in completing these forms to ensure accuracy. The forms will help accelerate the process between our offices in verifying insurance and preparing for testing. After all forms are completed, fax them to Skill Tech DX at the above fax number. As a reminder, please complete all forms and fax them into our office ten (10) days prior to your scheduled test day. This will ensure proper and timely insurance authorization and prompt reimbursements for the highest allowable rate.
If you have not scheduled a reoccurring day for testing, please contact your consultant at your earliest convenience. We have found that having a Reoccurring Test Day helps streamline your diagnostic testing schedule. Remember, you can always reschedule your test day; however, we do require seven (7) days notification to minimize possible scheduling conflicts.
Seventy-two (72) hours prior to your scheduled test day, our scheduling department will call to confirm the start time, date, patient’s information & insurance authorizations. We understand that situations may arise where a last minute patient needs to be tested and cannot be pushed to the following reoccurring test day. Skill Tech DX, in our best efforts, will gladly accommodate your clinic.
The Forms Needed For Testing
“Patient Information Form” and the “Assignment of Benefits”
Please designate an “Office Contact Person(s)” in your clinic who will be responsible for the “Ordering Doctor” forms to be completely filled out. This person(s) should completely fill in the patients demographic, insurance, and employer information on the “Patient Information Form” and fax it into our office ten (10) days prior to your scheduled test day.
The “Assignment of Benefits” section, located at the bottom of the form, must be signed and dated by all patients on the day of testing.
Please Note: These sections must be completed. The patient needs to sign and date this form so it may be collected by the Technologist before the studies are performed.
“Green Lien” (Workers’ Compensation Patients only)
Please complete the “Green Lien” form and fax it into our office ten (10) days prior to your scheduled test day. This form is only required for Workers’ Compensation cases. A copy of the “Doctor’s First Report“ or “PR-2” should also be faxed with the Green Lien form. On the Doctors First Report it is beneficial to state, “I intend to perform diagnostic testing on this patient in my clinic.” Depending on which form you utilize, this statement should be written on line 19 labeled “Treatment Plan” or “Objective Findings” or on line 24 labeled “Further Treatment.” This may assure that pre-authorization is granted and a phone call may not be necessary.
Please Note: Workers’ compensation cases require the Letter of Medical Necessity, Patient Information Form, Signed Green Lien and the Doctor’s First Report/ PR-2 ten (10) days prior to the day of testing. It is imperative that all information is provided and available in the proper fashion for accurate and timely billing to take place on behalf of both your clinic and WMS.
“Patients’ Freedom of Choice Form” (All Patients)
Please hand out and have each patient sign the “Patients’ Freedom of Choice Form” for whom you prescribe diagnostic testing. This document informs the patient of their rights with regards to choosing a diagnostic testing supplier. The patients may elect to utilize your facility as an affiliate of Skill Tech DX, however, it is important that they are properly informed of their options
Please Note: When a patient schedules a test with your facility you must fax this signed form to Skill Tech DX prior to testing. If we have not received this form prior to the test day, the technologist can not perform the test until a signed copy is handed to the technologist or faxed to Skill Tech DX.
“Letters of Medical Necessity” (Doctor’s Test Order Form)
To assure our clients the utmost professional service, we have provided your office with a “Letter of Medical Necessity” also known as a “Doctor’s Ordering Form.” This form must be filled out completely, signed by the ordering doctor and faxed into our office ten (10) days prior to your scheduled test day. This provides the medical information needed and the doctor’s orders for your patient to be tested. Our technologist must have this form in order to perform the diagnostic studies. It also serves as a “Template” so we may transfer all information from this form into a formal letter of medical necessity on your behalf to substantiate the necessity for testing. The Letter of Medical Necessity is used to help assure that studies will be covered by your patient’s insurance company and is utilized by the interpreting physician.
Please Note: In order to ensure proper reimbursement for your diagnostic test services, make sure that all the sections of the Letter of Medical Necessity are completely filled out and correspond to the studies being ordered.
i.e.: In most cases if ordering an Upper Profile, it would reflect upper extremity symptoms. The key is to be thorough with checking off the patient’s complaints, examination, findings, working diagnosis, and ICD-9 codes.
Ordering complete profiles will help the interpreting physician give you and your patients the most complete and thorough interpretations.
An Upper or Lower Neuro Profile consists of:
- NCV
- DEP
- SSEP
An Upper Musculoskeletal Ultrasound consists of:
- Cervical C1-C7
- Thoracic T1-T6
- Bilateral Trapezius muscles
Other MSUS studies that are available for the upper extremities are the shoulder, elbow, wrist and hand.
A Lower Musculoskeletal Ultrasound consists of:
- Thoracic T7-T12
- Lumbar L1-L5
- Bilateral SI joints
Other MSUS studies that are available for the lower extremities are the hip, knee, ankle, and foot.
Information & Indications on diagnostic Studies
Neurodiagnostic Studies
These Neurodiagnostic studies are non-invasive procedures of recording and studying the electrical activity of the brain and nervous system. These procedures gather vital information in regards to your patient’s neuromuscular system. Electrodes are placed on the surface of the skin over specific nerve sites to stimulate primary nerves. An electrical impulse is sent through electrodes to stimulate the nerve for a recorded response. Neurodiagnostic studies evaluate and measure the speed and intensity of electrical signals that travel along the nerves and calculate their ensuing velocities for abnormalities.
There are several types of Neurological tests that are performed by Skill Tech DX:
NCV- Nerve Conduction Velocities measure both motor and sensory nerve function to record their action potentials. The time it takes for the nerve to respond is measured during this process as well. NCV’s identify peripheral nerve dysfunction and neuropathies. NCV’s assist in such diagnosis as:
| Plexopathy | Peripheral Neuropathies |
| Nerve Root Compression | Entrapment Neuropathies |
| Neuritis / Neuralgia | Radiculopathy / Radiculitis |
| Disc Syndrome | Carpal / Tarsal Tunnel Syndrome |
| Myelopathy | Cubital Tunnel |
DEP- Dermatomal Evoked Potentials evaluate areas that are supplied with nerve fibers by one single nerve root. These studies can document injury and help substantiate further treatment in cases with uncertain disc bulges on a MRI or CT scan.
SSEP- Somatosensory Evoked Potentials evaluate the sensory nervous system by studying the function of the peripheral nerves through the spinal cord into the brain. SSEP’s assist in such diagnosis as:
| Herniated Disk | Multiple Sclerosis |
| Plexopathy | Spinal Cord Tumor / Trauma |
| Radiculopathy | Neuritis |
| Myelopathy | Disc syndrome |
Indications / Symptoms for Neurodiagnostic Studies
| Pins and Needles | Arm / Hand / Leg / Foot Pain |
| Head / Spinal Trauma | Radiating Pain |
| Numbness / Tingling | Extremity Pain |
| Headaches / Dizziness / Vertigo | Weakness of Extremities |
| Burning / Shooting / Stabbing Pain | Wrist / Foot Drop |
| Cold Hands / Feet | Muscle Atrophy / Cramping |
| Neck / Back Pain | Aphasia / Dysphasia |
The Time Needed to Complete an Upper or Lower Profile
| Full Upper Profile (NCV, DEP, and SSEP) | 60 Minutes |
| Lower Profile (NCV, DEP, and SSEP) | 60 Minutes |
Note: It is not recommended to perform Upper & Lower Profile on the same date of service.
Additional Benefits of Performing Neurodiagnostic Studies
- Provides supporting documentation for all legal cases
- Substantiates continued treatment plans to the insurance companies
- Localizes an area of injury and assesses its severity
- Verifies the effectiveness of the treatment program
- Assists Negative X-Rays, CT-Scans and MRI, while patient complaints persist
- Informative data if patient is not responding to treatment as expected
- For non-resolving, radicular pain
- The determination of nerve irritation
- To rule out nerve root and spinal cord compressions
- Evaluates for Herniated Disc
- Real vs. Imagined Pain
- Avoid turning patient towards Allopathic System of Care
- When the patient’s subjective complaints don’t support the objective findings
- Patients adhere to their treatment plan on a regular basis
- Creates an additional revenue stream
- Avoid losing patients as referrals to other outside facilities
Musculoskeletal Ultrasound (MSUS)
MSUS- Musculoskeletal Ultrasound is a non-invasive study that uses high frequency sound waves to create images of the body and provide information about the overall morphology of the body structures. This test is helpful in differentiating soft tissues and can also show inflammation in the spine, ligaments, tendons, and muscles.
Indications/Symptoms for Musculoskeletal Ultrasound
| Cervical and Lumbar pain | Polymyositis and Dermatomyositis |
| Lumbosacral Plexus | Muscle Atrophy |
| Muscle Cramping | Myositis Ossifications |
| Brachial Injury / Irritation | Tendonitis / Bursitis Tears / Lesions |
| Weakness of Extremities | Fibrous Scars |
The Time Needed to Complete a Musculoskeletal Ultrasound
| Full Upper MSUS study | 30 Minutes |
| Full Lower MSUS study | 30 Minutes |
| Upper & Lower MSUS Study | 60 Minutes |
Please Note: Time necessary to complete both a Neuro Profile & MSUS is (2) Hours
Vascular Examinations (VAS)
Doppler Ultrasound Duplex Venous combine Doppler ultrasound and B-mode imaging to maximize the anatomic and physiological information regarding the deep veins in the upper and lower extremities, including the major axial deep veins in the lower leg and the intramuscular veins. Ultrasound characteristics may imply an acute versus chronic process. This exam has replaced venography as the standards for detection of deep thrombosis.
Color Flow Doppler Scanning (Velocity & Flow) adds Doppler information encoded as color-flow to the conventional duplex scan to survey the arteries throughout their course. This test is reserved for those patients being evaluated for an invasive interventional procedure (laser, angioplasty, or surgery). It can identify all lesions as stenosis or occlusions estimate the percentage of diameter reduction and determine the length of the lesion. In cases where the angiography is contraindicated, color-flow scanning has been used at many hospitals in lieu of angiography for planning the surgical approach. Postoperatively, this test also is used to monitor bypass grafts for detection of conditions heralding impending graft failure so that appropriate intervention is taken prior to thrombosis.
Noninvasive Peripheral Venous & Arterial Evaluation Testing allows diagnosis and evaluation of deep and superficial venous thrombosis and valvular insufficiency. These procedures are rapid, repeatable and cost effective.
Peripheral Vascular Studies is an arterial evaluation that can document the presence of disease, determine its functional severity, localize the site of involvement, define the lesion as a stenosis or occlusion, measure its length and provide baseline information for future comparisons. When musculoskeletal system disease is also present, the evaluation will determine the contribution of arterial insufficient to the patient’s symptoms.
Indications/Symptoms for Vascular Testing
| Cold or Painful Toes | Symptomatic Varicose Veins |
| Red or Blue Toes | Heavy Legs (pt complaint, not visual) |
| Thickening Toe Nails | Edematous Legs |
| Hair Loss on Digits and/or Limb | Chronic Leg Pain and Tiredness |
| Limb Pain during Exercise (Walking) | Acute Leg Pain with Heat and Edema |
| Limb Pain at Rest | Vertigo |
| Ischemic Ulcers | Syncope |
| Gangrene | Amaurosis |
| Male Impotency | Migraine Headache |
Physiological Vascular Testing
Lower Extremity Arterial Studies Pneumoplethysmographic (segmental) waveforms and systolic blood pressure measurements at various limb levels identifies areas of regional hypotension. Selected arterial Continuous Wave Doppler Ultrasound velocity signals are analyzed audibly and by waveform morphology analysis in addition to quantitative velocities to localize the level of disease to the inflow, outflow or runoff vessels. Pneumoplethysmography and or photoplethysmography of the digits identifies the presence, severity and location of microangiopathy.
Vascular Stress Testing This study provides a medium for evaluating the functional significance of arterial occlusive disease in the claudicant. Upon completion of a maximum walk of five minutes, arterial signals and blood pressures are reassessed at the ankle level. The magnitude of decrease and time to return to baseline establishes the severity and functional significance of arterial obstruction. Stress testing is useful in differentiating the pain of arterial insufficiency from that of other conditions such as arthritis and neuropathies, and assists in identifying those patients whose symptoms of fatigue are due to coronary or pulmonary disease rather than arterial insufficiency.
Lower Extremity Venous Studies Continuous Wave Doppler Ultrasound velocity signals are used in combination with compression maneuvers to determine a variety of auditory indicators. Pressure changes in air-filled cuffs (pneumoplethysmography) quantify the venous capacitance and maximum venous outflow, while venous reflux (as measured by PPG) determines venous refill time. These test modalities are used to evaluate those patients with valvular incompetence (venous insufficiency) and deep vein thrombosis (DVT).
Upper Extremity Arterial Studies Pneumoplethysmographic (segmental) waveforms and systolic blood pressure measurements identify the presence, severity and location of obstructive disease or trauma. Pneumoplethysmographic and or photoplethysmographic waveform contours of the digits obtained under ambient conditions and during reactive hyperemia identify digital artery obstructions as fixed or functional. These test modalities are also used in the evaluation of patients with cold sensitivity diseases, microangiopathy and Thoracic Outlet Syndrome.
Carotid Asymmetry Index Peak Systolic and End Diastolic Continuous Wave Doppler Ultrasound velocities are assessed via two distinct algorithms to determine the presence, severity, and location of Carotid Occlusive Disease. By means of direct assessment and Periorbital Doppler, additional extracranial arteries may also be evaluated.
High-Risk Patients (for Physiological Vascular Testing)
| Diabetes Mellitus | T.I.A.’s (Transient Ischemic Attacks) |
| Hyperlipedemia | 25+_ pack/year smoker, symptomatic |
| Known ASHD (Atherosclerotic Heart Disease) | Smokers on Birth Control Pills |
| Hypertension | Family history of vascular disease |
| Absence of or Modified peripheral arterial pulses | Patients sent out for venograms |
| Asymptomatic or Symptomatic bruit | Patients sent out for arteriograms |
In Addition, Patients Suspected of
| Embolic/Thrombolic phenomena | Thoracic Outlet Syndrome |
| Vascular occlusive disease of Peripheral vascular disease | Raynaud’s phenomenon |
| Venous valvular insufficiency | Monckeberg’s sclerosis |
| Superficial or Deep Venous Thrombosis (D.V.T) | |
| Thrombo-angiitis obliterans (Buerger’s disease) |
Insurance Coverage Protocols
Because these diagnostic studies are so valuable to the treatment and care of your patients, most insurance companies cover the costs of these studies. All patients will be authorized by Skill Tech DX through its verification department. There are three types of patients on which you can expect coverage:
- Private Insurance (excluding HMO’s)
- Workers’ Compensation
- Personal Injury (with Med-pay)
It is very important that our office receives all patient information in a timely manor.
All patient information and signed forms must be received ten (10) days prior to the regular scheduled test day for pre-authorization and verification of coverage.
WMS will inform you of which patients are eligible for testing. If for some reason the studies are not covered and are medically necessary, Skill Tech DX, in its best efforts, will accommodate such studies.
E & M codes
In addition to your Affiliated Center fee, you may also be entitled to bill for your time associated with consulting your patient about the test results! These are Evaluation & Management (E&M) services.
Each E & M code has a “time factor” attached to it. This part of the E & M code is defined by CPT as the amount of time the physician typically spends “face-to-face” with the patient and/or family. As such, it includes sitting down with the patient (and/or family) and explaining the test results, what the implications/findings of the test results are, and answering your patient’s questions.
Listed below are the CPT codes and time factors for established patient office visits:
– 99211 5 minutes
– 99212 10 minute
– 99213 15 minutes
– 99214 25 minutes
– 99215 40 minutes
It is important that you clearly document in the patients medical records the amount of time you spend providing this serviced to your patients. By doing so, you protect yourself in case an insurance company should ask for patient records or perform an audit of paid claims. The documentation in the patient medical records must support the level of care for which you are billing. Additionally, when you share the diagnostic results/findings with the patient, it may “boost” the level of E & M care for which they are able to bill, based on the overall amount of time they personally spend with the patient.
This is yet another valuable service that you are providing to your patients so don’t forget to inform your billing department to add these E&M CPT codes and bill for these services when necessary. It is additional revenue to which you may now be entitled for consulting your patients about his or her test results.
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The following are links to documents containing the forms that you will need in order to begin testing patients through Skill Tech DX. We look forward to working with you and of course, please do not hesitate to call us for any reason.
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WELCOME ABOARD!
Skill Tech DX