DEPARTMENT: Governmental Operations Support
/ POLICY DESCRIPTION: Orders for Outpatient Tests and ServicesPAGE: 1 of 5 / REPLACES POLICY DATED: April 6, 1998; April 1, 2000
APPROVED: August 28, 2001 / RETIRED:
EFFECTIVE DATE: September 15, 2001 / REFERENCE NUMBER: GOS.GEN.004
SCOPE: All Company affiliated hospitals performing and/or billing ancillary services. Specifically, the following departments:
Business Office Nursing
Admitting/Registration Health Information Management
Medical Staff Physician Office Staff
Central Scheduling Ancillary Departments
Revenue Integrity Reimbursement
Administration Allied Health Practitioners
Medicare Service Centers Patient Account Services
Utilization Management
PURPOSE: To establish guidelines outlining the documentation required to support complete outpatient test and service orders in accordance with Medicare, Medicaid and other federally-funded payer guidelines.
POLICY: Orders for outpatient tests and services are valid provided they are documented and include the data elements as defined in this policy. Absent specific exceptions and consistent with Federal and State law, tests and services must be provided based on the order of physicians or allied health practitioners (AHP) acting within the scope of any license, certificate, or other legal credential authorizing practice in the state in which the facility is located.
The following examples are exceptions to this policy that apply to Medicare beneficiaries as Medicare does not require an order to provide the following services:
· Screening mammography;
· Influenza virus vaccine and its administration; and
· Pneumococal pneumonia vaccine (PPV) and its administration.
DEFINITIONS:
Allied Health Practitioner (AHP): Any non-physician practitioner permitted by law to provide care and services within the scope of the individual’s license and consistent with individually granted clinical privileges by the facility’s Board of Trustees. For example, certified nurse-midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists.
Ancillary Services: Hospital or other health care organization services other than room and board and professional services. Examples of ancillary services include diagnostic imaging, pharmacy, laboratory and therapy services.
Authentication: An author’s validation of his or her own entry in a document. Methods may include written signatures, rubber-stamps, faxed signatures or computer “signatures” depending on state law, and medical staff bylaws. Only the physician or AHP ordering the test or service may perform authentication. State regulations and medical staff bylaws, rules and regulations specify whether AHP orders require countersignature by a physician.
Custom Profile: A physician specific group of commonly ordered laboratory tests or panels which have not been defined by the AMA or CMS that are medically necessary in treating a patient’s condition. Custom profiles are for use by the defining physician only and an acknowledgement must be signed by the physician on an annual basis. Reference the Custom Profiles Policy, GOS.LAB.007.
Qualified Individuals: Those persons qualified by specific state rules, regulations and facility medical staff bylaws to accept orders for outpatient tests or services.
Protocol: Guideline of services to be performed for patients with a given condition. Protocols must be valid and approved in accordance with medical staff bylaws, rules and regulations, state and federal regulations and rules of accrediting agencies. Note: Orders for tests or services may be supported by a valid, approved facility protocol. Protocols may also be referred to as standing or routine orders.
PROCEDURE:
1. Registration and ancillary department personnel must review outpatient orders to verify required data elements exist as outlined below. Each category listed below (Test or Service Orders, Coding, Billing) is mutually exclusive. In addition, custom profiles and protocols can be considered valid orders provided they meet the requirements specified in the definition section of this policy.
Test or Service Orders:
The following elements are needed to support the performance and charging of a test or service. Please note all elements need not be in the same document, but may be found in many areas.
· Reason for ordering test or service (i.e., diagnosis, sign, symptom, ICD-9-CM diagnosis code)
· Test or service requested
· Orders reduced to writing
· Given only by authorized Physician or AHP
· Received only by Qualified Individual
· Name of Physician or AHP ordering test or service
· Address of Physician or AHP ordering test or service
· Phone Number of Physician or AHP ordering test or service
· Physician or AHP authentication ordering test or service
· Patient name
· Current dates - date order given, date/time order entered into patient record and date/time of authentication by responsible practitioner.
Coding:
The following list represents those minimum elements required to code tests or services.
· Reason for ordering test or service
· Test or service requested
· Orders reduced to writing
· Name of Physician or AHP ordering test or service
· Patient name
Billing:
The following list represents those minimum elements required to submit a bill for payment of a test or service.
· ICD-9-CM diagnosis code
· Tests or services ordered, charged or performed
· Name of Physician or AHP ordering test or service
· UPIN, State License, or Payer Specific Number of Physician or AHP
· Patient name
· Patient date of birth
· Patient sex
· Patient Social Security Number
· Patient demographics/insurance information
· Client number
2. If information from the order is missing, staff members receiving the outpatient order must attempt to obtain the required information. Every effort should be made to obtain all information prior to tests being performed or services being rendered. However, if patient care or the integrity of a specimen is at risk, continue processing the test(s) or performing the service(s) and subsequently obtain required elements. Refer to Attachment A – Written Verification of Verbal and Incomplete Orders.
3. Physician or AHP authentication must be obtained as defined by medical staff bylaws, rules and regulations and enforced by hospital policy and procedure. Facilities may code and bill the account without an authenticated order; however, the order must eventually be authenticated.
4. All staff responsible for ordering, registering, performing, charging, coding or billing outpatient tests or services must be educated on the contents of this policy.
5. Monitoring of this policy must be conducted in accordance with the monitoring requirements of Medicare – Medical Necessity, GOS.GEN.002.
6. Business office personnel must identify intermediary interpretations which vary from the interpretations in this policy. Specific documentation from the intermediary related to the variance(s) must be obtained and provided to the Billing Help Line at 1-888-735-3669.
The Facility Ethics and Compliance Committee is responsible for implementation of this policy within the facility.
SPECIAL CONSIDERATIONS:
Resident Physicians: It is acceptable for a resident physician to order a test or service provided the facility's medical staff bylaws, rules and regulations authorize resident physicians to be granted the privilege of ordering tests or services.
Verbal Orders: The facility's medical staff bylaws, rules and regulations must define who can relay verbal orders and must be based upon state law defining who is licensed to order such tests or services. The facility's medical staff bylaws, rules and regulations must define who, by title or category, can accept and document verbal orders. Refer to Attachment A – Written Verification of Verbal and Incomplete Orders.
Standard Laboratory Requisition: A standardized laboratory requisition form has been developed and should be used for outpatient laboratory services.
REFERENCES:
Medicare Conditions of Participation
Medicare Intermediary Manual 3920.1; 3660.7
Medicare Hospital Manual 451
Medicare Carrier’s Manual 2050.2
State Operations Manual – Tag # A102-A104
42 CFR 482.23; 482.24; 482.26b.4
JCAHO IM 7.7; 7.8
JCAHO MS 2.5
Licensure and Certification Policy, QM.002
9/2001
Attachment A
Written Verification of Verbal and Incomplete Orders
The facility is required to obtain written verification for all verbal and/or incomplete test or service orders. The items circled below are required to complete the processing of the test or service order. Please complete the information, sign below as written verification of the verbal request, and fax or mail to:
Facility NameAddress Line One
Address Line Two
City. State, Zip Code
Phone/Fax Number
Reason for Order:
Verbal Order Additional Test or Service Ordered Incomplete Order Received
Other:______
Date: / Time: / Ordering Physician/AHP:
UPIN: / Requested By:
Physician Address: / Physician Office Phone Number:
Physician Office Fax Number:
Patient Name: / Patient Sex: / Patient Birthdate: / Patient SSN:
Patient Address: / Patient Insurance:
Test(s)/Service(s) Ordered
/ICD-9-CM diagnosis code, Diagnosis, Sign or Symptom
Physician/AHP Signature:
/Date:
Physician Countersignature (if required):
/Date:
Person Receiving Order:
/Date:
For Recurring Orders Only:Order Start Date: / Order End Date: / Frequency:
Attachment to GOS.GEN.004