By:Jacqueline Thelian, CPC, CPC-I, CHCA
Whether you are a Diagnostic Testing Facility, an Independent Laboratory or a Physician who received referrals, you need to make sure your orders are valid and validated.
Valid orders include at minimum, the patient’s name, test(s) ordered, indication for the test(s), a clear and legible name of the ordering physician, the ordering physician’s signature and date of the signature. Remember signature stamps are not valid.
However, on many occasions the order is incomplete and/or illegible.
CMS as well as many other insurers are now asking the “rendering” provider to validate the order.
As per CMS, “The physician who treats a beneficiary must order all diagnostic x‐ray tests, diagnostic
laboratory tests, and other diagnostic tests for a specific medical problem. Documentation in the patient’s medical record must support the medical necessity for ordering the service(s)”
CMS goes on to say, “However, it remains the responsibility of the individual or entity upon whom/which the request has been made to provide documentation.”
Therefore, in order to validate the request for the test, it is the responsibility of the rendering/servicing provider to produce the patient’s medical progress note from the ordering physician which documents the test(s) ordered as well and the medical necessity and indication for the test.