The Centers for Medicare
& Medicaid Services (CMS), is continuing to focus on lowering the
Comprehensive Error Rate Testing (CERT) claims paid error rate. Currently, one
area of concern identified in the CERT data is denial of diagnostic tests due
to missing physician/non-physician practitioner order or intent within the
medical record. This has led to the recoupment of overpayments by Novitas
Solutions, Inc totaling over $355.64. More importantly, when CMS and CERT
extrapolate these errors to the universe, they will account for approximately
$22.1 million in claims payment errors for the November 2012 report.
Medicare defines a Diagnostic Test as including:
"All diagnostic x-ray tests, all diagnostic laboratory tests, and other
diagnostic tests furnished to a beneficiary."
And further defines Clinical Laboratory Services as:
"The biological, microbiological, serological, chemical,
immunohematological, hematological, biophysical, cytological, pathological, or
other examination of materials derived from the human body for the diagnosis,
prevention, or treatment of a disease or assessment of a medical
condition."
CMS also gives direction that Clinical Laboratory Services "must be
ordered and used promptly by the physician who is treating the
beneficiary."
CMS defines an order as:
" A communication from the treating physician/practitioner requesting that
a diagnostic test be performed for a beneficiary. The order may conditionally
request an additional diagnostic test for a particular beneficiary if the
result of the initial diagnostic test ordered yields to a certain value
determined by the treating physician/practitioner (e.g., if test X is negative,
then perform test Y)."
An order can be written in the beneficiary's record or can be a telephone order
from the physician's office to the testing facility. If a telephone
order, both the treating physician and the testing facility must have
documented in the beneficiary's record the telephone call and the extent of the
diagnostic tests being ordered.
Although CMS does not require the order to be signed by the physician, the
physician must have clearly documented in the beneficiary's record the intent
to order the diagnostic test.
Documentation requested by the CERT contractor or Novitas Solutions, Inc to
support the order for the diagnostic test (or the physician's intent to order),
will be sent to the testing facility, as it is the facility that is billing for
the test. Often the testing facility is unable to provide the
physician's order or intent because this information is in the beneficiary's
record in the physician's office. The testing facility has to
request this information from the physician in order to be paid for the
service. Without the order for the test, or the intent to order, both the
CERT contractor and Novitas Solutions, Inc will deny payment for the diagnostic
test or service.
To avoid such denials, testing facilities and physician's offices need to work
together. Testing facilities should attempt at the time the beneficiary
is presenting to the facility, to have a diagnostic test performed, to obtain a
physician's order. This can be accomplished by directing the beneficiary
to bring a prescription that includes the condition or diagnosis code for which
the diagnostic test is ordered as well as the order for the diagnostic test. If
the beneficiary presents without a valid order, the testing facility could call
the physician's office to obtain a telephone order for the diagnostic test.
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