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CMS issues test order signature clarification

Radiology Administrator's Compliance and Reimbursement Insider, December 1, 2008

CMS issues test order signature clarification

CMS recently released an update to the Medicare Benefit Policy Manual, clarifying physician signature requirements for clinical diagnostic tests. Specifically, the update (Change Request 6100, Transmittal 94) stated that physician signatures are not required on orders for diagnostic tests paid based on the Clinical Laboratory Fee Schedule, the Medicare Physician Fee Schedule, or for physician pathology services. CMS accidently left the stipulation out of the manual when it was originally published. Before CMS issued the August revision, Medicare contractors were routinely rejecting claims that lacked a physician signature.

The clarification means one less arduous task for radiologists, says Jean Acevedo, LHRM, CPC, CHC, PCS, president and senior consultant at Acevedo Consulting in Delray Beach, FL. However, they still need to make sure the intent of the ordering physician is clear, Acevedo says.

“The good news for radiologists is they no longer have to track down physicians and ask them to fax over signatures,” she explains. “We conduct compliance auditing of several different radiology groups and, up until now, we have always required the code and the signed order. Now we won’t be looking for any physician signature—just documentation that the order is there.”

It isn’t likely to alter practice operations much, says Stacy Gregory, RCC, CPC, owner and senior consultant at Gregory Medical Consulting Services in Tacoma, WA. However, radiologists can breathe a sigh of relief regarding the time saved from searching for physician signatures, she says.

Confusion regarding signature requirements

Some providers are still unsure about when it is necessary to verify signatures.

This is especially true as CMS recently passed an-other rule stating it will no longer accept medical records with a physician signature stamp, says VeronicaMarsich,Esq., at Smith Haughey Rice and Roegge in Ann Arbor, MI.

That rule modified CMS’ Medicare Program Integrity Manual and mandated the use of handwritten or electronic signatures in documentation in lieu of a signature stamp. It’s no surprise that providers may not know what to do, particularly because these two changes came out so close to one another, Marsich says.

“It has created some confusion in the sense that there are other components of the manuals that say when a signature is required, it has to be original,” she says. “The point is, if the documentation requires a signature, make sure it doesn’t have a stamp. But in the case of diagnostic tests, they don’t need it at all.”

“I tell them they don’t have to do anything except make sure the order is clear,” says Acevedo, who has already received questions from imaging centers.

Marsich says she is also optimistic that the revision will stop contractors from returning claims and refusing payment because of physician signature. “I really don’t think there will be any delay in payment on the contractor side of things,” she says. “Now that the revision is clearly stated in the manual, they don’t have any room to disregard it.”

Items to watch

Although the transmittal alleviates some burden from providers, it’s important to look closely at the language of the revision, says Acevedo. In addition to stating that no signature will be required for diagnostic tests, CMS also states that “while a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed.”

It is important to note that even though radiologists don’t have to look for a signature, they still have to make sure that intent to perform the test is well documented, Acevedo says. “What that means, essentially, is that radiologists need to make sure their intake scheduling person has enough education and is able to document orders correctly when they come in over the phone,” she says. “They need to be able to clearly understand the ordering physician’s intent.”

Providers should remember that this revision does not change any prior CMS directives regarding ordering requirements for interpreting physicians, Acevedo says. Specifically, interpreting physicians still cannot step outside the bounds of an order without having a discussion with the ordering physician and requesting a new test order, if needed, she explains. (See “What CMS says about signature changes” at right for the official language.)

The absence of a physician signature does not nullify those ordering requirements, Acevedo says, and adds, “I would really stress that because it can be very easy to forget.”

Physicians’ signing rules

As a general practice, physicians are often advised to sign any requisition for service, so radiologists may see no difference at all, says Marsich. In fact, it would be ideal if the clarification served as protection from contractors in potential disputes, rather than triggering a big change in protocol, she says.

“Physicians have in the back of their mind that signatures are important,” Acevedo says. “And, of course, they protect radiologists, too. I wouldn’t suggest that any radiology practice discourage treating physicians from signing orders. Still, it’s a nice thing that radiologists don’t have to search them out anymore.”

What CMS says about signature changes

CMS’ Medicare Benefit Policy Manual states the following regarding signature requirements on diagnostic test orders:

When an interpreting physician (e.g., radiologist, cardiologist, family practitioner, general internist, neurologist, obstetrician, gynecologist, ophthalmologist, thoracic surgeon, vascular surgeon) at a testing facility determines that an ordered diagnostic radiology test is clinically inappropriate or suboptimal, and that a different diagnostic test should be performed (e.g., an MRI should be performed instead of a CT scan because of the clinical indication), the interpreting physician/testing facility may not perform the unordered test until a new order from the treating physician/practitioner has been received.

Similarly, if the result of an ordered diagnostic test is normal and the interpreting physician believes that another diagnostic test should be performed (e.g., a renal sonogram was normal and based on the clinical indication, the interpreting physician believes an MRI will reveal the diagnosis), an order from the treating physician must be received prior to performing the unordered diagnostic test.

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