Health Information Management

Tip: Distinguish between orders, requisitions for diagnostic tests

APCs Insider, February 12, 2010

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In the 2010 Medicare Physician Fee Schedule final rule, CMS restates its self-described “long-standing” policy that requires ordering physicians or nonphysician practitioners to sign the written order for diagnostic tests such as x-rays and laboratory tests. CMS says its policy does not require signatures on requisitions for laboratory tests.
 
CMS defines an “order” as a communication from the treating physician or practitioner requesting that a laboratory perform a diagnostic test for a beneficiary. Orders may be conveyed via:
  • A written document signed by the treating physician/practitioner that is hand delivered, mailed, or faxed to the treating facility
  • A telephone call
  •  E-mail or other electronic means
 
CMS says a “requisition” is the actual paperwork, such as a form, that physicians provide clinical diagnostic laboratories to identify the test or tests they want performed. The requisition may contain details such as:
  • Patient information
  • Billing information
  • Specimen information
  • Test selection
CMS stated in the final rule that a requisition signed by a physician may serve as an order.
 
This tip is adapted from “CMS clarifies physician signatures needed on all lab orders” in the February issue of Briefings on APCs.



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