DEPARTMENT: Governmental Operations Support / Billing Compliance Support

/ POLICY DESCRIPTION: Orders for Outpatient Tests and Services
PAGE:1 of 5 / REPLACES POLICY DATED: April 6, 1998
APPROVED: February 2, 2000 / RETIRED:
EFFECTIVE DATE: April 1, 2000 / REFERENCE NUMBER: GOS.GEN.004
SCOPE: All Company affiliatedfacilities performing and/or billing ancillary services. Specifically, the following departments:
Business Office Nursing
Admitting/Registration Health Information Management
Medical Staff Physician Office Staff
Central Scheduling Ancillary Departments
Revenue Integrity Reimbursement
Administration External Coding Consultants
Internal Audit & Consulting Ethics & Compliance
Revenue Service Center Medicare Service Center
PURPOSE: To ensure outpatient test and service orders are properly documented in accordance with Medicare, Medicaid and other federally-funded payor guidelines.
POLICY: Orders for outpatient tests and services must be documented and include the data elements as defined in this policy. Absent specific exceptions and consistent with Federal and State law, tests and services must be provided based on the order of physicians or allied health practitioners (AHP) acting within the scope of any license, certificate, or other legal credential authorizing practice in the state in which the facility is located. The following examples are exceptions to this policy that apply to Medicare beneficiaries as Medicare does not require an order to provide the following services:

Screening mammography; and
Influenza virus administration and vaccine.

PROCEDURE: Orders for outpatient tests/services must be processed as follows:
1.Absent a specific exception (e.g., screening mammography) and consistent with Federal and State law, tests and services must be provided based on the order of physicians or AHP acting within the scope of any license, certificate, or other legal credential authorizing practice in the state in which the facility is located. For the process of ensuring that a physician or AHP is licensed, see Licensure and Certification Policy, QM.002.
2.It is acceptable for a resident to order a test or service provided the facility's medical staff bylaws and/or rules and regulations authorize residents to be granted the privilege of ordering tests or services.
3.It is acceptable for an AHP to order a test or service provided that the individual ordering the test or procedure is acting within the scope of any license, certificate, or other legal credential authorizing practice in the state in which the facility is located and state regulations specify whether the item(s) ordered must be countersigned by a physician.
4.Orders of AHPs do not need to be countersigned provided that the individual ordering the test or procedure is acting within the scope of any license, certificate, or other legal credential authorizing practice in the state in which the facility is located.
5.The facility's medical staff bylaws and/or rules and regulations must define who can accept and document verbal orders. Refer to Attachment A – Written Verification of Verbal and Incomplete Orders.
6.The facility's medical staff bylaws and/or rules and regulations must define who can relay verbal orders and must be based upon state law defining who is licensed to order such tests or services.
7.Physician or AHP authentication must be requested within 24 hours (or in compliance with state law if state law is stricter). Facilities may code and bill the account without an authenticated order; however, the order must eventually be authenticated. Authentication timeliness should be defined by medical staff bylaws and/or rules and regulations and enforced by hospital policy and procedure.
8.A standardized laboratory requisition form has been developed and should be used for outpatient laboratory services.
9.Each facility must follow medical necessity guidelines and only perform and charge for tests/services which have been ordered by a Qualified Individual. The following outlines the required documentation to support complete test or service orders, coding and billing of outpatient services. Each category listed below (Test or Service Orders, Coding, Billing) is mutually exclusive.
Test or Service Orders:
The following elements are needed to support the performance and charging of a test or service. Please note all elements need not be in the same document, but may be found in many areas.

Reason for ordering test or service (i.e., diagnosis, sign, symptom, ICD-9-CM diagnosis code)

Test or service or therapies requested
Orders reduced to writing
Given only by authorized Physician or AHP
Received only by Qualified Individual
Name of Physician or AHP ordering test
Address of Physician or AHP
Phone Number of Physician or AHP
Physician or AHP authentication
Patient name

Current dates - date order given, date/time order entered into patient record and date/time of authentication by responsible practitioner.

Coding:
The following list represents those minimum elements required to code tests or services.

Reason for ordering test or service

Test or service or therapies requested
Orders reduced to writing
Name of Physician or AHP ordering test or service
Patient name

Billing:
The following list represents those minimum elements required to submit a bill for payment of a test or service.

ICD-9-CM code
Tests or services or therapies ordered, charged or performed
Name of Physician or AHP ordering test or service
UPIN, State License, or Payor Specific Number of AHP
Patient name
Patient date of birth
Patient sex
Patient Social Security Number
Patient demographics/insurance information
Client number

IMPLEMENTATION:
1. Ancillary department, outpatient scheduling departments and business office personnel should educate all staff, physicians, and AHPs responsible for ordering, registering, performing, charging, coding or billing outpatient tests or services regarding the requirements of this policy.
2.The Facility Billing Compliance Committee must review the requirements and implementation of this policy on a monthly basis in accordance with GOS.GEN.002 (Medical Necessity). Deviations from this policy should be documented and resolved in accordance with the “Billing – Auditing & Monitoring” Policy, GOS.GEN.001.
3.Business office personnel must identify intermediary interpretations which vary from the interpretations in this policy. Specific intermediary documentation related to the variance(s) must be obtained and faxed to 615-344-2734, Attn: Billing Compliance – Intermediary Interpretations.
DAILY:

Registration and ancillary department personnel must review outpatient orders to ensure required data elements exist. If information from the order is missing, staff members receiving the outpatient order must attempt to obtain the required information. Every effort should be made to obtain all information prior to tests being performed or services being rendered. However, if patient care or the integrity of a specimen is at risk, continue processing the test(s) or performing the service(s) and ensure required elements are subsequently obtained by designated personnel. Refer to Attachment A – Written Verification of Verbal and Incomplete Orders.

Outpatient orders must be properly filed, accessible, and retained for a period of at least seven (7) years unless State law or Company policy stipulates a longer period of time.

It is the responsibility of the Chief Financial Officer to ensure adherence to this policy.
DEFINITIONS:
Authentication: Way for an author to validate his or her own entry in a document. Methods may include written signatures, rubber-stamps, faxed signatures or computer “signatures” depending on state law, and medical staff bylaws and/or rules and regulations. Only the physician or AHP ordering the test or service may perform authentication.
AHP: Any non-physician practitioner permitted by law to provide care and services within the scope of the individual’s license and consistent with individually granted clinical privileges by the facility’s Board of Trustees. For example, certified nurse-midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists.
Qualified Individuals: Those persons qualified by specific state rules, regulations and facility medical staff bylaws and/or rules and regulations to accept orders for outpatient tests or services.
REFERENCES:
Medicare Conditions of Participation
Health Information Management, Revised by The American Health Information Management Association (1994) Tenth Edition
Attorneys’ Textbook of Medicine, Third Edition (11/84)
Medicare Intermediary Manual 3920.1; 3660.7
Medicare Hospital Manual 451
Medicare Carrier’s Manual 2050.2
State Operations Manual – Tag # A102-A104
42 CFR 482.23; 482.24; 482.26b.4
JCAHO IM 7.7; 7.8
JCAHO MS 2.5
Licensure and Certification Policy, QM.002

Attachment A

Written Verification of Verbal and Incomplete Orders

The facility is required to obtain written verification for all verbal and/or incomplete test or service requests. The items circled below are required to complete the processing of the test or service order. Please complete the information, sign below as written verification of the verbal request , and fax or mail within 24 hours to:

Facility Name
Address Line One
Address Line Two
City. State, Zip Code
Phone/Fax Number
Reason for Request:
Verbal Request Add on Test or Service Requested Incomplete Order Received
Other:______
Date: / Time: / Ordering Physician/AHP:
UPIN: / Requested By:
Physician Address: / Physician Office Phone Number:
Physician Office Fax Number:
Patient Name: / Patient Sex: / Patient Birthdate: / Patient SSN:
Patient Address: / Patient Insurance:

Test(s)/Service(s) Requested

ICD-9 Code, Diagnosis, Sign or Symptom

Physician/AHP Signature:

Date:

Person Receiving Request:

Date:

For Standing Orders Only:
Order Start Date: / Order End Date:
(No more than 6 months) / Frequency:

Attachment to GOS.GEN.004