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Order errors

Compliance Monitor, October 20, 2006

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Q: Can a radiologist change the physician orders in the physician setting if they are clearly wrong according to the patient's clinical signs and symptoms (e.g., clinical indications call for CT angiography rather than CT)? Does the ordering physician have to be notified or issue another order?

A: CMS' ordering of diagnostic tests rule (Medicare Carriers Manual 15021, Transmittal 1725) provides for clear error.

The document states that "the interpreting physician may modify, without notifying the treating physician/practitioner, an order with clear and obvious errors that would be apparent to a reasonable layperson [e.g., x-ray of wrong foot ordered]."

This scenario may also fall under the "test design" exception to the rules for ordering diagnostic tests. Unless specified in the order, the interpreting physician may determine, without notifying the treating physician/practitioner, the parameters of the diagnostic test [e.g., number of radiographic views obtained, thickness of tomographic sections acquired, and use or nonuse of contrast media].

Find diagnostic test supervision and ordering requirements for hospitals in 42 CFR.

Thanks to Stacy Gregory, RCC, CPC, principal, Gregory Medical Consulting Services, Tacoma, WA, for answering this question.

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