Proper documentation is key if billing is expected.

Here’s a fairly common scenario for technicians: Mrs. Jones, a patient, has complaints of decreased vision that does not improve with a careful refraction. The technician reads the chart and, based on one of the patient’s previous diagnoses, “knows” the doctor will want an OCT of the retina.

Is this proper? Can the practice bill this test to insurance?

While knowledgeable about the patient’s possible disease, the technician is not licensed. As a result, she cannot order a test. Secondarily, if payers question the billing, they want to see that the test is properly ordered. Here, I’ll deal with the relevant citations and help with the example above. (Note that I won’t deal with the considerations on the “interpretation and report” [see tinyurl.com/OPCoding7171 ] or the “supervision rules” for diagnostic tests).

Medicare’s ruling

Medicare has a longstanding set of guidelines on this: “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” (http://tinyurl.com/OPCoding7172 ). Other payers generally follow Medicare’s rules or publish something similar on their own.

The citation also adds that non-physician practitioners, such as physician assistants, when acting within their authority and state scope of practice, are treated the same as physicians for purposes of this paragraph. However, they cannot be the supervising physician here (in this case, it is who is “supervising” the PA). Also, optometrists and nurse practitioners acting within their respective scope of practice are already considered physicians for purposes of this Medicare rule. Therefore, it’s clear that a physician order is required — and it should come from the provider who actually treats the patient.

The best practice answer

Returning to the opening question, what should you do if you are the technician? In our example above, the technician should get the doctor’s input. The doctor’s order must be specific to the individual patient and condition and cannot be a “standing order.” The doctor might want to see the patient to see what tests could apply, of course. The technician or scribe should then record the order in the paper or electronic medical record (EMR) and perform the test(s) that the physician orders. The regulations for some previous years related to meaningful use of EMRs (as it relates to computerized provider order entry) required scribes and techs to have certification or some form of credentialing to record the test order, but those requirements no longer exist in 2017. A provider also can’t tell the technician to perform gonioscopy or extended ophthalmoscopy — those are considered “physician-only” tests.

Standing orders are those that the physician gives for a situation and not for a specific patient/condition. Therefore, they do not convey insurance coverage — although the patient might be responsible if he is given notice and agrees in advance of testing. Also, remember that tests are sometimes ordered on a prior visit, so the technician should look there in the chart as an order might already exist. It’s usually found at the end of that prior visit note — typically in the “Impression/Plan” area.

Referral scenarios

I also receive questions about situations in which a chart arrives from an outside, trusted doctor. For example, after reviewing the chart, if the doctor says, “Mr. Smith is coming as a new patient work-in later today from Dr. Adams. I’ve never seen the patient before. I just got off the phone with Dr. Adams, and she already sent me the chart notes via secure email. I want you to get the tests I noted on those records when he arrives.” In this case, the doctor has specific information about the patient in question from both phone and medical records, so this would not be considered a standing order.

One final reminder

Sometimes payers ask for records, and tests are a part of those requests. The practice should provide not only the test results/images and interpretation for that date but also the order (which might require retrieval by pulling and send that section of the prior visit). A recent spate of payer reviews has focused on proper order documentation, so it’s important to give them what they need to agree your documentation is all there. Without the order documentation, the payer might doubt whether the test was medically necessary.

Conclusion

Having an order properly documented before performing a test is imperative if you expect that the test may be billable. There are a number of ways to handle this, but in the end you must still obtain a valid order and be able to reproduce it if questioned. Failure to do so makes the test non-billable and likely to be a “patient-pay” service.

As always, “Good Coding” to you! OP

Mr. Larson is a senior consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.