CMS SOM App. A, Tag A-0539

clinical privileges or, consistent with State law, of other practitioners authorized by the

medical staff and the governing body to order the services.

Interpretive Guidelines §482.26(b)(4)

The medical staff and the governing body determine the necessary qualifications and clinical

privileges that practitioners must have to order diagnostic radiologic studies or therapeutic

procedures.

For outpatient services, the governing body and medical staff may also authorize practitioners

who do not have hospital privileges to order such studies or procedures, as permitted under State

law. For example, a hospital may decide that it will routinely accept orders from physicians in

the communities it services for outpatient diagnostic studies, regardless of whether those

physicians have privileges to practice in the hospital. See the guidance for §482.54(c) for more

information on requirements related to outpatient orders from practitioners who do not hold

privileges to practice at the hospital.

The order must include information for the radiologic technologist about the study or procedure

to be performed, and the technologist is expected to review this information prior to

implementing the order.

For Information Only – Not Required/Not to be Cited

Hospitals are strongly encouraged, but not required, to develop standard formats for

practitioner’s orders for radiologic services that clearly document the diagnostic or therapeutic

purpose of the study/procedure, as well as any other pertinent information that may lead to

altering the dose of radiation, including, but not limited to:

• Indication (reason) for the study/procedure

• Previous imaging studies of the body part(s) under investigation;

• Additional relevant radiation exposure; and

• Previous adverse events (e.g., over- or underexposure of dosing, allergic reaction to

contrast dye) during radiologic procedures.

In addition, hospitals are encouraged to adopt policies to ensure that the radiation technologist

performing the study/procedure confirms the order with the ordering practitioner if there are

any concerns about its appropriateness.

Survey Procedures §482.26(b)(4)

• Review medical records to determine that there is an order for all radiologic services, and

that the order was dated/timed and authenticated by an authorized practitioner prior to the

diagnostic study or therapeutic procedure being performed.

Observe whether a radiologic technologist confirms that there is an order from an authorized

practitioner and reviews information included in the order before beginning a study or procedure.