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Orders in the Hospital Setting

By Melody Mulaik

The guidelines for the ordering of diagnostic tests in the non-hospital setting have been around for 20 years. This information is found in the Medicare Benefit Policy Manual, Chapter 15, Section 80.6.

People sometimes incorrectly think there are no guidelines to follow for ordering services provided in a hospital setting which is not the case. The ordering of diagnostic tests in the hospital setting is governed by the Medicare Conditions of Participation (COP) for hospitals. These are found in the Code of Federal Regulations, 42 CFR §482.

The standard for medical record content [42 CFR §482.24(c)] states: “All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with state law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules and regulations.”

The standard also states that the hospital may use preprinted and electronic standing orders, order sets and protocols. However, these must be: Reviewed and approved by the medical staff and by the nursing and pharmacy leadership; consistent with nationally recognized and evidence-based guidelines; reviewed regularly by the medical staff and nursing and pharmacy leadership; and dated, timed and authenticated promptly by the ordering physician or practitioner in the patient’s medical record. Alternatively, this may be performed by another practitioner who is responsible for the care of the patient, but only if he or she is acting in accordance with state law, hospital policy and medical staff bylaws, rules and regulations.

The radiologic services standard regarding patient and personnel safety [42 CFR §482.26(b)] states: “Radiologic services must be provided only on the order of practitioners with clinical privileges or, consistent with state law, of other practitioners authorized by the medical staff and the governing body to order the services.”

This means that all diagnostic tests must have an order documented and authenticated in the patient’s medical record, and the order must match the test that was performed. The ordering physician can be any physician who is authorized by the hospital’s medical staff to order diagnostic tests. All tests must be medically necessary, and the documentation supporting medical necessity must be in the patient’s hospital record.

The COP do not specify that the patient’s treating physician must be the ordering physician, but some Medicare contractors have stated that an order from the patient’s treating physician is required to support medical necessity. Providers should review any guidance published by their local contractor. Keep in mind that published audit results from Medicare contractors and the Office of Inspector General (OIG) have frequently identified a high volume of errors due to lack of a physician order, an unsigned order or an order that does not match the test performed.

Hospitals should have a process in place to ensure that all diagnostic tests have orders that are signed by an authorized provider and match the study performed. If the hospital allows the radiologist to order diagnostic tests, then a process should also be developed to ensure that any changes made by the radiologist are documented and authenticated in the same manner that the original orders are documented and authenticated. Both radiologists and hospitals are potentially subject to refund obligations if there are not appropriate orders for performed services.

Melody W. Mulaik, MSHS, CRA, RCC, RCC-IR, CPC, COC, FAHRA, is the president of Revenue Cycle and Coding Strategies Inc.

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