Health Information Management

Q&A: Why did the auditor disallow our order?

APCs Insider, August 23, 2013

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Q: An external company audited our outpatient cardiology department. Our physicians write an order for "Lexiscan® Cardiolite®," which we know is a stress test and nuclear medicine test including the administration of both Lexiscan and Cardiolite. The auditor disallowed the charges for lack of an order. We know what they mean, so what is the big deal? 

A: The "big deal" is that Lexiscan is a drug, and while it may be administered only for stress tests, ordering the drug is not the same as ordering the test.

Cardiolite is a radiopharmaceutical used for myocardial perfusion studies, but is not the perfusion study.

When the physician orders Lexiscan, you can argue that the physician is implying that this is a stress test. That is not what the physician ordered.

You have to separate your assumption about what the physician wants based on the drug from CMS' stance that the order must be specific for the procedure/test/service that the physician intends for the individual patient. CMS and its entities (RAC, MAC, CERT, etc.)  do not accept assumptions about what  of physicians order, and that will be their argument.

Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.



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