Health Information Management

Q/A: Necessity of complete orders

APCs Insider, November 2, 2012

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Q: During a recent audit, an audit stated the orders for our stress tests were “insufficient.” One physician writes an order for “Cardiolite® adenosine” which is a stress test with myocardial perfusion study. The auditor stated this order is insufficient and is asking for monies to be returned. We all know what this means but the auditor wasn’t convinced.

A: The order as written is incomplete because it doesn’t describe a specific procedure – it describes a radiopharmaceutical and drug. 
The order should contain all the elements for the procedures that the physician intends to be performed. For example, “adenosine stress test and myocardial perfusion study with Cardiolite” is a complete and comprehensive order. 
Over time, providers have created an understanding of what an order is supposed to mean, but the physician must write an order for the service or you cannot report a HCPCS code for a procedure. In order to support the service of a cardiac stress test with adenosine and myocardial infusion study with Cardiolite, the order must state that. 
This is similar to the complete blood count (CBC) vs. CBC with differential situation that Comprehensive Error Rate Testing auditors have reviewed over time. The physician orders a CBC and the facility reported a CBC with differential because coders understood that to be what the physician intended; however, the order indicated something else.
To insure the integrity of the OPPS and non-Medicare payer revenue you receive, work with your practitioners on the necessity of complete orders and not medical shorthand. This will ensure that the test/procedure/service provided is clearly stated and supported by physician/practitioner intent. There will be no interpretation or question for external reviewers.
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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