Urology Coding Alert
Don't Code 'Standing Order' Urinalysis Tests
Question: I just read the Urology Coding Alert article "81001-81003? The Order May Clinch the Auditor's Decision." I have a question about standing orders. For example, if a group is using an EMR, and a urinalysis is almost standard. Over 90 percent of the patients get an UA (81001). The results are entered in the required fields setup in the EMR. The physician acknowledges he reviewed under microscope, indicates his findings, and the results are scanned into the system. What I see to be incorrect is there is no actual order for the UA. Because this group considers this a continuity of care, an order is never obtained. Is a "standing order" applicable/legal?
Michigan Subscriber
Answer: Standing orders are never acceptable for ordering a test. An order should be available for each performed and ordered test.
The rule: Diagnostic tests always require an order for the test based on clinical signs or symptoms (for example, pain or hematuria for a urinalysis) or for evaluation of a particular diagnosis. Standing orders often represent screening of the patient, and many payers do have separate screening codes that should be used.
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