Form CMS-10221 Site Investigation for Independent Diagnostic Testing Fa

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved

OMb No. 0938-1029

Independent dIagnostIc testIng FacIlItIes—sIte InvestIgatIon
42 cFR § 410.33
Date Ordered: _________________________

Date of First Visit: ______________________

Time: ______________________

Date of Second Visit: ______________________

Time: ______________________

1. Reason FoR vIsIt
Initial/Change

Revalidation

Hearing & Appeal

Ad Hoc

2. FacIlIty InFoRmatIon
Facility Name

National Provider Identifier (NPI)

Name of Authorized Representative(s) or Interviewee(s)

Name of Authorized Representative(s) or Interviewee(s)

Name of Authorized Representative(s) or Interviewee(s)

Name of Authorized Representative(s) or Interviewee(s)

Practice Location (Physical Street Address)
City

State

Zip Code

business Telephone Number

3. FacIlIty InspectIon
a. peRFoRmance standaRd #3
performance standard #3 requires IDTFs to maintain a physical facility on an appropriate site.
(photogRaph RequIRed)
Office Suite-Mall

Office Suite-Office building

Private Residence

Warehouse

Other. Please describe: _____________________________
1. Is the ITDF located on an appropriate site?
If no, describe:

___________________________________________

2. Is the IDTF handicap accessible?
If no, describe:

___________________________________________

3. Were there patients in the facility during the inspection?
If no, describe:

___________________________________________

4. If this IDTF is at a fixed location, does the facility contain adequate space
for testing, including all tests listed on the enrollment application, facilities
for hand washing, adequate patient privacy accommodations, and storage
of business and medical records?
If no, describe:

Form CMS-10221 (08/12)

No

Yes

No

Yes

No

Yes

No

N/A

Yes

No

N/A

___________________________________________

5. If this IDTF is a mobile facility, does the mobile unit have access to facilities
for hand washing, adequate patient privacy accommodations, and a home
office location for the storage of business and medical records?
If no, describe:

Yes

___________________________________________

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B. peRFoRmance standaRd #4
performance standard #4 requires IDTFs to have all applicable diagnostic testing equipment available at the
physical site (excluding portable diagnostic testing equipment).
1. Does the IDTF maintain a catalog of portable diagnostic equipment,
including diagnostic testing equipment serial/registration numbers, at the

physical site?

If no, describe:

Yes

No

N/A

Yes

No

Yes

No

___________________________________________

4. Has the IDTF provided updates to the MACs regarding equipment changes
in accordance with existing regulation?

If no, describe:

N/A

___________________________________________

3. Does the IDTF maintain a current inventory of diagnostic equipment,
including diagnostic testing equipment serial/registration numbers?

If no, describe:

No

___________________________________________

2. Did the IDTF make the portable equipment or mobile unit(s) available for
inspection?

If no, describe:

Yes

___________________________________________

c. peRFoRmance standaRd #5

performance standard #5 requires IDTFs to maintain a primary business phone under the name of the business.

1. Is the business telephone located at the IDTF or within the home office
for the mobile IDTF?

If no, describe:

No

Yes

No

___________________________________________

2. Is the business telephone number listed in local telephone directory or
is it available through directory assistance?

If no, describe:

Yes

___________________________________________

d. peRFoRmance standaRd #6
performance standard #6 requires IDTFs to have comprehensive liability insurance in the amount $300,000 per
facility.
1. Did the IDTF provide proof of insurance upon request?
If no, describe:

Yes

No

___________________________________________

e. peRFoRmance standaRd #7
performance standard #7 states that IDTFs must agree not to directly solicit patients; this includes, but is not
limited to, a prohibition on telephone, computer, or in-person contacts.
How does the IDTF solicit new business? Describe:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

F. peRFoRmance standaRd #8

performance standard #8 requires IDTFs to maintain a protocol regarding beneficiaries’ complaints.

1. Does the supplier have a written complaint resolution procedure
Yes
No
established?

If no, describe:
Form CMS-10221 (08/12)

___________________________________________

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g. peRFoRmance standaRd #9

performance standard #9 requires IDTFs to post these standards for beneficiary review.

1. Has the IDTF posted the standards found at 42 CFR § 410.33 in the IDTF or
home office for a mobile IDTF?

If no, describe:

Yes

No

___________________________________________

h. peRFoRmance standaRd #11
performance standard #11 requires IDTFs to have their diagnostic equipment calibrated and maintained per
manufacturer’s equipment instructions and in compliance with applicable manufacturer’s suggested maintenance
and calibration standards.
1. Does the IDTF have proof that diagnostic equipment has been calibrated
and maintained per equipment instructions in accordance with
manufacturer’s instructions?
If no, describe:

No

Yes

No

___________________________________________

2. Did the IDTF provide a copy of the maintenance log upon request?
If no, describe:

Yes

___________________________________________

I. peRFoRmance standaRd #12
performance standard #12 requires IDTFs to have technical staff on duty with the appropriate credentials to
perform the tests.
1. Can the IDTF furnish the applicable Federal/State licenses and/or
certifications for the individuals performing these services?
If no, describe:

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

___________________________________________

2. Can technical staff identify the supervising physician(s)?
If yes, list name(s) of supervising physician(s) that was provided by the
technician. _______________________________________________
If no, describe:

___________________________________________

3. Is the supervising physicians(s) on site?
If no, describe:

___________________________________________

4. Did the IDTF provide a written list of the technician(s) that will be
furnishing services at this IDTF upon request?
If no, describe:

___________________________________________

5. Did the IDTF provide a written list of the supervising physician(s) that will
be supervising services at this IDTF upon request?
If no, describe:

___________________________________________

J. peRFoRmance standaRd #13
performance standard #13 requires IDTFs to have proper medical record storage and be able to retrieve medical
records upon request within 2 business days.
1. Can the IDTF retrieve medical records within 2 business days?
If no, describe:

___________________________________________

2. Does the IDTF have proper medical records storage?
If no, describe:

___________________________________________

Yes

No

Yes

No

3. How are the records stored?
On-site
Form CMS-10221 (08/12)

Electronically

Storage Facility

Other: _______________________
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K. peRFoRmance standaRd #14
performance standard #14 requires IDTFs to permit CMS or it’s Contractors to conduct unannounced on-site
inspections to confirm the IDTF’s compliance.
1. Is the IDTF accessible during regular business hours?
If no, describe:

Yes

No

Yes

No

___________________________________________

2. Does the facility maintain posted hours of operation?
a. If yes, list hours of operation below:
monday

tuesday

Wednesday

thursday

Friday

saturday

sunday

b. If no, describe: _________________________________________________
l. peRFoRmance standaRd #15
performance standard #15 states that with the exception of hospital-based and mobile IDTFs, a fixed-base IDTF is
prohibited from the following:
•

Sharing a practice location with another Medicare-enrolled individual or organization;

•

Leasing or subleasing its operations or its practice location to another Medicare-enrolled individual or
organization; or

•

Sharing diagnostic testing equipment used in the initial diagnostic test with another Medicare-enrolled
individual or organization.

1. Does the IDTF share its practice location?
If yes, describe:

Form CMS-10221 (08/12)

Yes

No

Yes

No

__________________________________________

3. Does the IDTF lease or sublease its operation or its practice?
If yes, describe:

No

__________________________________________

2. Does the IDTF share diagnostic equipment?
If yes, describe:

Yes

__________________________________________

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4. addItIonal questIons FoR InspectoR
A. Was the inspector able to complete the site visit?
If no, describe:

Yes

No

___________________________________________

b. Additional Comments (if none, please check N/A)

C. beyond what is disclosed in this site visit worksheet, was there any
evidence obtained during the site visit that could indicate that the

supplier is not in compliance with the provisions in 42 CFR 410.33?

If yes, describe:

N/A

Yes

No

__________________________________________

D. Photographs Required
Photograph exterior of building (including business sign & hours of operation if possible)
Photograph interior facility entrance if located within a a multiple tenant building (business signs & hours
of operation, if possible)
E. Inspector’s Information and Signature
I prepared this document, which is the report of my inspection of the noted facility pursuant to their
enrollment in the Medicare program. This report is a true and accurate account of the events that occurred
and transpired on the date(s) reported herein that this site visit was performed. I am capable and willing
to testify as a witness at a hearing about the content of this report. The foregoing information is based on
my personal knowledge or is information provided to me in my official capacity. I declare under penalty or
perjury that this information is true and correct to the best of my knowledge and belief.
Executed this _____ day of ________________________, 20_____
Signature of Declarant
Printed Name
Organization

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMb control number. The valid OMb control number for this information collection is 0938-1029. The time required to complete this
information collection is estimated to average 2 hours per response, including the time to review instructions, search existing data resources,
and gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, baltimore, Maryland 21244-1850.
Form CMS-10221 (08/12)

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