Medicare has identified a recent increase in the number of CERT errors attributed to the lack of physician orders for diagnostic tests. 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/her office to the testing facility; and
- An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records.
NOTE: While a physician order is not required to be signed on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services; the physician must clearly document, in the medical record, his or her intent that the test be performed. Failure to do so may result in denial of the service which may subsequently lead to the patient being responsible for payment. Furthermore, the absence of a signature on an order may lead to a medical record audit of the ordering physician to verify that the physician's intent is indeed documented as directed in the regulation. Therefore, HMS recommends that physicians provide their signature on all orders for diagnostic and laboratory services.
Make sure that your office, billing, and/or laboratory staffs are aware of this updated guidance regarding the signature requirement for diagnostic tests and are complying with this regulation. Also, note that in keeping with standard auditing principles, items such as signatures, attestations, and other addendums which are added to the medical record after the date of the Additional Documentation Request (ADR) letter will generally not be considered as acceptable documentation. Furthermore, providers who exhibit a pattern of adding documentation after ADR requests could be subject to corrective action.
If you receive a request for medical records from the CERT contractor or Highmark Medicare Services, it is critical that the signed physician order for all diagnostic tests be included. Without the order, the services could be determined to be medically unnecessary and the claim will be denied.