Health Information Management

Q/A: Ensure that physician orders are complete

APCs Insider, December 23, 2011

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Q: Our facility recently was audited and cited for our inadequate myocardial perfusion stress test orders. Despite lengthy discussions about this concern, we remain somewhat perplexed as to why our orders are unacceptable and what we should do to improve them. The auditors questioned orders that read, “Lexiscan™ stress test” or “SPECT w/Regadenoson”. Our physicians always want a stress test and myocardial perfusion study, which is what we do. Can you explain why these orders are considered inadequate and offer a suggestion for improvement?

A: Abbreviated orders are a problem that many facilities face today. Orders such as “we know what the physician means” or “that is what the physician wants” don’t pass the completeness test. CMS and non-Medicare payers are looking for specific expressions of physician intent that a particular test is warranted for an individual patient. “Always” performing a test or combination of tests does demonstrate show individual care of a patient; it shows a “population order.”

Based on your statement, the myocardial perfusion portion of the stress test is inferred/implied but not definitively communicated. Without direction from the ordering/treating physician, you cannot show support for intent of the service. Consider this citation in the Code of Federal Regulations, Title 42 regarding the Medicare Program:

§ 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.

(a) Ordering diagnostic tests. All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.

The examples you provide indicate the orders support a stress test performed with Lexiscan/Regadenoson, but the physician did not document an order for a myocardial perfusion scan or the radiopharmaceutical used for the myocardial scan.

Remedy this situation by ensuring that physicians document the complete and specific services they’re ordering. In your example, the order should reflect all portions of the study, such as “Regadenoson cardiac stress test with nuclear myocardial perfusion study.” With this specificity, the order supports or justifies performing and reporting a cardiovascular stress test, a myocardial perfusion study, a radiopharmaceutical, and a pharmacological stressing agent.

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



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