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Tip: Encourage documentation at time of order

Patient Financial Services Weekly Advisor, June 4, 2004

If you need to appeal to Medicare to pay your outpatient/emergency department (ED) claim, you'll need proper documentation to support your cause. That's where documentation at time of order comes into play.

Valerie Rinkle, MPA, revenue cycle director at Asante Health System in Medford, OR, suggests adding a box in the order paperwork for the ED physician to indicate that he or she ordered test(s) based on the presenting condition of the patient.

Also, other managed-care plans that usually deny services ordered in the ED may pay if you present the ordering documentation in this manner, she says.

To qualify for payment, a physician's interpretation must take place before EMTALA screening is complete and the patient is stable, says Rose T. Dunn, RHIA, CPA, FACHE, FHFMA, chief operating officer of First Class Solutions, Inc., in St. Louis.

Documenting the time at which the physician makes an interpretation for ordered tests is crucial in reimbursement, so educate ED physicians on the importance of documenting it in their dictation, written notes, or wet reads, Dunn adds.

"If you can show the test was ordered for EMTALA and that the order was based on presenting conditions, you should get paid for that test," Rinkle says. "As long as the test was ordered prior to the EMTALA screening being completed, payers have to pay because it falls under the umbrella of EMTALA."

Interpretation report formats should include the following elements to support medical necessity:
(1) A place to document the treating physician's/practitioner's ordering indications
(2) A space to document the technologist's indications taken from the patient
(3) An area to document the interpreting physician's final impression

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