Pathology/Lab Coding Alert

Perform diagnostic tests without a signed order --here's how.

If past Medicare direction left you unsure whether your lab could perform a test ordered without a signature, you can rest better now.

 A recent CMS transmittal states that you do not need a physician's signature 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."

Although past direction in the Medicare Carrier's Manual left no room for debate, CMS omitted the following language during the conversion to the internet-only manuals and left coders wondering if it still applied:

"Medicare does not require the signature of the ordering physician on a laboratory service requisition. While the signature of a physician on a requisition is one way of documenting that the treating physician ordered the service, it is not the only permissible way of documenting that the service has been ordered. For example, the physician may document the ordering of specific services in the patient's medical record."

Then earlier this year, a program contractor muddied the waters by stating that Medicare will not pay for lab-test orders without a physician signature.

Follow new guidance: To streamline its advice, CMS issued Transmittal 94, which covers the differences between "treating physicians" and "ordering physicians," and discusses when you must have a physician's signature on file and when you don't need one.

Putting the signature issue to rest requires that you understand the long-confusing term "physician order," which CMS clarifies in the transmittal.

"Many practices consider an order a written piece of paper, but that isn't always the case," says Heather Corcoran, coding consultant with CGH Billing in Louisville, Ky.

Reality: A physician order is "a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary," the transmittal says.

The order can be hand-delivered, mailed, or faxed to the testing facility if the physician has written it down. However, CMS notes that the order can also be communicated via telephone or e-mail.

Do this: If you have a test ordered on the phone, both the ordering and treating practitioners have to make sure to document it in the patient's medical record, says Jay Neal, an Atlanta-based coding consultant.

For example: When a physician communicates an "order" for a diagnostic test, such as a CBC with differential (85025, Blood count; complete [CBC], automated [Hgb, Hct, RBC, WBC, and platelet count] and automated differential WBC count) for a beneficiary via a telephone call to the lab, documentation must include these items:

- The physician/practitioner or his/her office must document the telephone call, and the physician must document "his or her intent that the test be performed," in the beneficiary's medical record

- The lab must document the phone order in its copy of the beneficiary's medical record.

Signature debate settled: Although many coders dispute this fact, CMS clearly says in its transmittal that the physician order need not be signed. But the ordering physician must document his intent in the medical record, and the lab must document that they performed the test.

To read the transmittal, go online to http://www.cms.hhs.gov/transmittals/downloads/R94BP.pdf.

For further instruction, see the provider education article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6100.pdf.