Orders for Diagnostic Testing

TrailBlazer Health Enterprises® – Carrier/FI for Colorado, New Mexico, Oklahoma, Texas and Virginia.

Due to the recent increase in the number of errors identified during the Comprehensive Error Rate Testing (CERT) contractor audit for the lack of physician orders for diagnostic tests, TrailBlazer recommends that providers sign all orders for testing and/or progress notes showing the intent for testing to be completed.

• Along with a legible signature, the order and/or medical record should have a legible identifier (e.g., the physician’s printed or typed name below the signature).
• The physician’s signature should be in the form of either a handwritten signature or an electronic signature.
• Stamped signatures (i.e., rubber stamps) are not acceptable signatures.

While a written order for tests is not required to be signed by the ordering physician, lack of a signature could result in a request for medical records from the ordering physician and/or denial of the diagnostic test. If there is no written order for the test, the physician must clearly document in the patient’s medical record the intent that the test be performed. Claims submitted for diagnostic testing could be denied if the following are not present in the medical record:

• Documentation of intent for the test to be completed.
• Legible signature.
• Legible identifier.

A diagnostic test includes all diagnostic X-ray tests, all diagnostic laboratory tests and other diagnostic tests furnished to a beneficiary.

An order is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:

• A written document signed by the treating physician/practitioner, which is hand-delivered, mailed or faxed to the testing facility.
• A telephone call by the treating physician/practitioner or his office to the testing facility. Or,
• An e-mail by the treating physician/practitioner or his office to the testing facility.

If the order is communicated via telephone, both the treating physician/practitioner or his office and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.