Health Information Management

Q&A: Requirements for drug panels ordered in the ED

APCs Insider, May 1, 2015

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Q: When a patient presents to the ED and the physician there orders a drug panel, we perform the entire panel. Is that physician supposed to only order the tests for drugs that he or she suspects the patient has taken, according to the new CPT® drug reporting requirements?
 
A: All services require a physician/practitioner order. Section 1862(a)(1)(A) of the Social Security Act states that Medicare may not make payment for services that are not reasonable and necessary. Documentation and physician orders support medical necessity.
 
Yes, Medicare's expectation for documentation of the specific drugs that the physician intends to screen for has been a requirement for quite a while. The reason is that there has to be medical necessity to support the service and the results. The documentation requirements in the Local Coverage Determinations for drug screening state:
 
Drugs, or drug classes for which testing is performed, should reflect only those likely to be present, based on the patient's medical history, current clinical presentation, and illicit drugs that are in common use. Drugs for which specimens are being tested must be indicated by the referring provider in a written order.
 
Even though the patient has presented to the ED, the documentation requirement remains. If the patient is known to have a history of drug abuse, which drugs did he or she historically abuse? If the patient has a history of seizures, but has been taking medication, what other drug(s) does the physician suspect (based on the individual history) could be causing the problem?
 
In some instances, especially in the ED, the physician does not have adequate information to determine what might be going on, or the clinical picture is so complex that there could be a lot of determining factors. However, there still has to be a mechanism to show that the physician intended to have the drugs screened. The documentation must support the service and the intent, even if the physician documents something like “Unsure of cause of clinical picture due to the following factors: X, Y, Z, etc. General drug panel ordered.”
 
The drug panel order can be crafted to have the physician select either the panel or the individual components, or delete components not indicated to make it easier for the physician. However, in order to bill for a service, the documentation must still support the intent and the medical necessity based on the individual situation.
 
Editor’s note: Denise Williams, RN, CPC-H, seniorvice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Fort Lauderdale, Florida, answered this question.



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