November 2012

Are Your Orders in Good Order? — Tips for Getting Your Ducks in a Row to Ensure Proper Orders and Reimbursement
By Melody W. Mulaik, MSHS, RCC, CPC, CPC-H, PCS
Radiology Today
Vol. 13 No. 11 P. 20

Ensuring proper orders for all performed exams is one coding and compliance issue that continues to plague radiology professionals. Numerous articles have been published about the Centers for Medicare & Medicaid Services (CMS) guidelines for ordering diagnostic radiology services, so instead of reorganizing this information into a new format, this article will present and address frequently asked questions on the topic.

It is important to remember that while the CMS guidelines for independent diagnostic testing facilities (IDTFs) and physician offices differ from the hospital guidelines, many private payers use one set of guidelines, regardless of the place of service. This article will focus on the CMS and private payers in a broad sense, but individual payer requirements for orders vary significantly. It is important for your process to incorporate a method for following your individual payer guidelines.

To make it easier to determine specific concerns by location, the questions addressed in this article will be divided into all locations, hospitals, and IDTFs/physician offices. Note that the hospital category will include hospital-based radiologists.

All Locations
Q: What constitutes a valid order?

A: A valid order must contain, at minimum, the patient’s name, the test requested, clinical indications for the test, and the name and signature of the treating physician.

Q: Where can I find the guidelines in the Medicare rules that define “valid physician’s order”?

A: Medicare’s definition of a valid order can be found in the Medicare Benefit Policy Manual, Chapter 15, Section 80.6. You also should review the following resources:

• The Social Security Act (§1862.a.1.A) states that for a test to be reasonable and necessary, it must be ordered by a physician, and the results must be used by that physician in the management of a beneficiary’s specific medical problem.

• The Medicare Claims Processing Manual (Chapter 23, Section 10.1.2) states that the ordering physician must provide the diagnostic information at the time the study is ordered.

• The Medicare Program Integrity Manual (Chapter 3, Section 3.2.4) provides information regarding signature requirements and examples of valid methods for authentication.

• Medicare Conditions of Participation (42 CFR §482.26) provide the requirements for hospital outpatient departments.

Q: At what point does the CMS consider an imaging order a “stale order”?

A: Hospitals or health systems may have a definition for stale orders at an enterprise level, which then applies to all types of services ordered within that hospital or health system. IDTFs or physician offices also should have a policy that addresses order validity. Payers that preauthorize or precertify imaging studies often include an expiration date. However, unlike prescriptions for medication, there is not a standard expiration date for imaging orders.

If there is ever a question about the validity of an order received for imaging services, the referring physician indicated on the order should be contacted for verification.

Q: When can an imaging facility perform a different exam without obtaining an updated order from the treating physician?

A: For Medicare, if an order does not specify the exam protocol—for example, the number of views or whether contrast should be used—the radiologist may make this determination based on the patient’s clinical indications without notifying the referring physician. This is usually referred to as a “test design” decision.

The radiologist also may change an order when it contains an error that would be obvious even to a layperson. For example, if the treating physician orders an X-ray of the left ankle to check the alignment of a patient’s fracture, but it is the right ankle that is fractured, the facility can perform a right ankle X-ray without contacting the referring physician.

If the patient’s condition will not permit the exam to be performed as ordered, the radiologist may cancel the exam without notifying the referring physician. Any medically necessary “scout” testing is payable.

There also is an exception to the ordering rules for situations when the radiologist determines that an additional exam is needed due to an abnormal result of the exam that the treating physician ordered but the treating physician is unavailable to provide an order. There are detailed requirements for providing and documenting the additional service (see Medicare Benefit Policy Manual, Chapter 15, Section 80.6.3).

Finally, the facility does not need a new or revised order to perform an exam that the treating physician conditionally ordered. For example, the physician orders a breast ultrasound after a diagnostic mammogram, if clinically indicated. You do not need an updated order if it is determined that the ultrasound exam is necessary.

If your system does not have the built-in capability for physicians to place conditional orders, updating your internal exam code to the conditionally requested study would not be considered an order change. If your computerized physician order entry system requires that you update the order to the conditionally requested study, you should verify that the original order with the conditionally requested study remains in the system.

Q: If the treating physician provides clinical indications that are not specific, can the study be performed or should the physician be contacted for additional information?

A: The ordering physician is required to provide valid indications for the imaging study being requested. For Medicare patients, you must have this information to determine whether an advance beneficiary notice (ABN) is necessary. If the indications for the exam are covered under a local coverage decision or are not specific enough for you to determine whether they are covered by it, then you have two options:

• You can contact the referring physician and request additional information because the clinical information provided does not meet Medicare’s coverage requirements. Be careful with this step, as it would be inappropriate to provide the physician with diagnoses that are covered and ask if any apply to the patient.

• You can issue the patient an ABN informing them that the clinical indications provided by their physician are not expected to be considered medically necessary by Medicare.

If the patient is not a Medicare patient, then there is no ABN notification requirement, but the patient’s payer may have its own coverage and notification requirements.

The determination to provide the study in absence of this information is both a financial decision and a clinical decision.

Q: Is an order required for 3D rendering?

A: All exams should have specific orders. The only exception is screening mammograms and diagnostic mammograms performed to evaluate an abnormality seen on screening mammograms, as allowed under the Mammography Quality Standards Act.

Hospitals
Q: What is the radiologist’s responsibility for authenticating orders when reading hospital services?

A: The facility staff, not the radiologist, should be responsible for determining whether an order is valid. However, it is recommended that the radiologist have access to the information contained in the order, along with any history recorded by the technologist, at the time the interpretation is dictated. This will help ensure that the radiologist understands what specific information the referring physician is looking for and that complete documentation of the clinical history is contained in the radiology report.

Q: Can the radiologist make changes to an order in the hospital setting?

A: The Medicare Conditions of Participation spells out the requirements for any services ordered in the hospital. The conditions can be found in 42 CFR §482.26(b)(4), which states that services must be provided only on the order of practitioners with clinical privileges or, consistent with state law, other practitioners authorized by the medical staff and the governing body. This means that all services provided by the hospital must have an order in the patient’s medical record, and the order must match what was provided.

A recent Office of Inspector General audit of emergency department patients found 18% of MRI and CT exams and 9% of X-rays lacked an order in the medical records. Its recommendation was that Medicare request a refund for all these services.

Second, as mentioned previously, the conditions state that services must be ordered by a practitioner with clinical privileges or another practitioner as allowed by state law and authorized by the hospital’s medical staff and governing body. Thus, radiologists may order exams as long as the hospital’s governing body authorized them to order services for patients.

All orders for diagnostic tests must be medically necessary; therefore, if an order is changed from what was originally requested, the medical necessity of the change also must be documented to support the revised order. For example, a CT lateral spine without contrast was ordered on a patient for trauma, contusion lower back. Upon screening the patient in radiology, it was determined that the patient has undergone back surgery, so the study needs to be performed with contrast. The radiology report should explain the reason for the change. This revised order must be authorized by the ordering physician or, if allowed by the hospital’s governing body, can be authorized by the radiologist. Regardless of the authenticating physician, a revised order must be obtained so that the study performed matches the study ordered.

Q: If an exam is performed without an order due to department protocol, is it appropriate to bill some patients when an updated order can be obtained and not bill others when you cannot get an updated order?

A: It is best not to perform any exam without an order. If this happens frequently, the referring physicians should be educated on the clinical indications that should trigger an additional study so that the appropriate imaging exam can be ordered without the need for requesting a revised order.

IDTFs/Physician Offices
Q: In an IDTF setting, is it appropriate to accept orders for Medicare beneficiaries that are signed with the physician’s name and then countersigned by someone else (eg, Dr Smith/Patty Jones)?

A: From a Medicare perspective, the orders must be signed by the ordering physician. For instructions regarding acceptable signatures, see Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4.

Q: Can an IDTF accept a verbal order?

A: The Medicare Claims Processing Manual (Chapter 35, Section 20) states the following:

All procedures performed by the IDTF must be specifically ordered in writing by the physician or practitioner who is treating the beneficiary, that is, the physician who is furnishing a consultation or treating a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. (Nonphysician practitioners may order tests as set forth in CFR 410.32(a)(3).)

The order must specify the diagnosis or other basis for the testing. The supervising physician for the IDTF may not order tests to be performed by the IDTF, unless the IDTF’s supervising physician is in fact the beneficiary’s treating physician. That is, the physician in question had a relationship with the beneficiary prior to the performance of the testing and is treating the beneficiary for a specific medical problem. The IDTF may not add any procedures based on internal protocols without a written order from the treating physician.

In other words, if the IDTF accepts a verbal order to set up an appointment for imaging, it must obtain the order in writing prior to performing the exam.

Final Caution
While many more questions about exam orders could be included in this article, I think this collection hits most of the common issues. Keep in mind that individual payer guidelines always prevail, and navigating these guidelines continues to become more challenging. It is important that management evaluate who is responsible for the heavily administrative task of ensuring correct orders and that clinical staff are not inappropriately burdened with this chore. There is great value in having clinical staff review the orders, but that does not translate into giving them the primary responsibility for obtaining correct orders.

— Melody W. Mulaik, MSHS, RCC, CPC, CPC-H, PCS, is president and cofounder of Coding Strategies Inc, which provides specialty-specific auditing and educational services for physicians, hospitals, and billing companies nationwide.