An “order” is defined 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 a certain value determined by the treating physician/practitioner. An order may be delivered via any of the following forms of communication:
If the order is communicated via telephone, both the treating physician/practitioner, or his or her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records.
What is a Test Requisition?
A “test requisition” is defined as the actual paperwork, such as a form, which is provided to a clinical diagnostic laboratory that identifies the test or tests to be performed for a patient. It may contain patient information, ordering physician information, referring institution information, information about where to send reports, billing information, specimen information, shipping addresses for specimens or tissue samples, and checkboxes for test selection. It serves as an administrative convenience to providers and patients. A requisition that is signed may serve as an order.
Proposed Signature Requirements for Clinical Laboratory Test Requisitions:
To simplify matters CMS proposes to require a physician's or non-physician professional's signature on requisitions for clinical laboratory tests paid on the basis of the Medicare Clinical Laboratory Fee Schedule. In other words, signatures would be required on both orders and requisitions, thus eliminating the confusion over exactly when they are required. To make things clear, we are repeating that starting in 2011, CMS plans to require signatures on all orders and requisitions for diagnostic tests, including clinical laboratory procedures.
Signature Guidelines for Medical Review Purposes:
The Medicare Program Integrity Manual requires a "legible identifier" in the form of a handwritten or electronic signature for every Medicare service ordered. Stamp signatures are not acceptable. If the signature is illegible, auditors may refer to a signature log or attestation statement to identify the ordering physician.
A handwritten signature is defined as "a mark or sign by an individual on a document to signify knowledge, approval, acceptance or obligation."
A signature log may be used to identify a physician associated with initials or an illegible signature. The signature log might be included on the actual page where the initial or illegible signature appears, or on a separate document. Auditors must consider all submitted signature logs regardless of the date they were created.