Dating and signing diagnostic test orders

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Understand when coders need to verify signatures Regardless of specialty, most coders will at some point need to review a medical record and verify that there is a proper signature from the ordering provider when certain tests or drugs are relevant for code assignment.

For lab services, providers’ offices often fax orders ahead of time or patients will present with the actual orders.

Before you send the first fax, be sure and let your physicians know that you are implementing this process because of incomplete orders.

Also, help educate the physicians on what is needed on the order.

Cassano, CPC Providers must understand the revisions to signature guidelines outlined in Med Learn Matters article 6698 and Transmittal 327 in the Medicare Program Integrity Manual, which were revised on April 26 to include additional clarifying language from CR 6698 and are retroactive to March 1 in order to satisfy the November 2010 reporting period.

These guidelines affect physicians, nonphysician practitioners, and suppliers submitting claims to Medicare fiscal intermediaries (FI), Part A/B Medicare administrative contractors (MAC), carriers, Recovery Audit Contractors (RAC), regional home health intermediaries, and durable medical equipment (DME) MACs for services provided to Medicare beneficiaries, according to Med Learn Matters article 6698.

They will have to ensure that the electronic medical record (EMR) or other software product they are using has adequate protection against modifications once a provider has electronically signed off on a record. Several days later, a comprehensive error rate testing (CERT) auditor requests the records for review.

Want to receive articles like this one in your inbox? Let’s take a closer look at the updated provider signature guidelines for labs and diagnostic testing.

For example, the physician may document in the medical record that he or she ordered specific services.

Consider the following June 14 Med Q&A related to lab tests: Question: When a prescription is missing one or more of the five requirements (specifically diagnosis code or physician signature) and you cannot contact the office for a verbal or fax (in the case of a missing signature), do you send the patient away to have them get a corrected prescription or have them wait until the correct information can be obtained?

CMS’ Medlearn Answer: The order needs to be a valid order to carry out the services.

We realize that there are times in which an order may not be complete, and the facility would like to carry out the service or test and get the missing information after the fact.

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