Compliance Focus

Ordering Diagnostic Tests – Medicare

Ordering diagnostic tests is an integral part of physicians’ and other clinicians’ activities. Medicare requires that all diagnostic tests be ordered by the clinician who is responsible for the patient’s care and that the clinician document the specific reasons for the diagnostic test in the patient’s medical record.

The following is excerpted from the Medicare Carrier’s Manual Section 15021:

An ‘order’ is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. … An order may include the following forms of communication:
• A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility;
• A telephone call by the treating physician/practitioner or his/her office to the testing facility; or
• An electronic mail by the treating physician/practitioner or his/her office to the testing facility.

If the order is communicated via telephone, both the treating physician/ practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records.

Medicare conditions of participation, as outlined in the Code of Federal Regulations at 42 CFR 482.24(c)(1), require that medical record entries be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing or evaluating the service furnished.

It is by virtue of the requirement to authenticate (sign) and date the medical record that Medicare does not require signatures on clinicians’ orders for diagnostic tests. Medicare considers the signature on the medical record in place of a signature on a requisition. In cases where ordering physicians and/or other clinicians do not sign the diagnostic testing order/requisition and do not specifically document the rationale for ordering diagnostic and other ancillary services in the medical record, Medicare refuses payment upon review. It is therefore imperative that all clinicians specifically document the rationale for ordering all diagnostic tests in the signed medical record.

For more information, call or e-mail Neil Walsh in the Billing Compliance Department at 617-732-9377 or via email (cwalsh6@partners.org).