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Pre-checking consults on a new CPOE system

Compliance Monitor, April 14, 2006

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Q: We are switching to computerized physician order entry (CPOE) and are building order sets for our common diagnoses and procedures.

We want to pre-check consults to physical and occupational therapy and speech for certain patient populations including stroke patients and orthopedic joint replacement patients.

Our compliance director tells us that CMS does not allow this and that the order must be individual to each patient and cannot be pre-checked.

We feel that this is evidence-based standard of care and should be permitted. Also, the physician could "un-check" the order if desired.

Who is correct?

A:Your compliance director is correct. It is appropriate for a health care institution to include a checklist of items and services that are appropriate for certain patient diagnoses on its clinical pathways. However, developing a default check on the actual billing software - while not illegal per se - is nonetheless strongly discouraged for several reasons.

First and most importantly, this type of practice creates an appearance that your facility is leading or encouraging physicians to provide specified services even if such services are not medically necessary or justified by the examination of the patient.

Additionally, this practice may subject the health care institution and physicians to fraud investigations for false claims.

The HCFA 1500 claim form expressly requires the physician to certify that services billed were medically indicated, necessary for the health of the patient, and personally furnished by the physician or furnished incident to the physician's professional service. Such medical necessity must be documented. The service for which payment is being sought must have been performed and documented in the patient's medical record.

If a billing claim form is prechecked, indicating that the physician performed a PT/OT consult on a stroke patient, the physician could be subject to charges of fraud and misrepresentation if the physician did not perform the service or if there is no evidence in the patient's medical record that such service was medically indicated, even if the billing error were a simple, unintentional mistake (i.e., the physician forgot to "uncheck" the PT/OT consult on the claim form). For these reasons, and to reduce the likelihood of a Medicare audit or fraud investigation, we routinely advise health care clients to avoid the practice of default billing.

Thanks to Jacqueline H. Finnegan of Garfunkel, Wild & Travis P.C. in Great Neck, NY for answering today's question.

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