OUTPATIENT ORDERS

Orders for outpatient tests and services must be in writing and include the data as defined in this policy. Absent specific exceptions and consistent with Federal and State law, tests and services must be provided based on the order of physician or allied health practitioner (AHP) acting within the scope of any license, certificate, or other legal credential authorizing practice in the state of North Carolina.

Orders for outpatient tests/services must be processed as follows:

• Consistent with Federal and State law, tests and services must be provided based on the written order of physician or AHP acting within the scope of any license, certificate, or other legal credential authorizing practice in the state of North Carolina.
  
• It is acceptable for a medical resident to order a test or service provided the facility's medical staff bylaws and/or rules and regulations authorize residents to be granted the privilege of ordering tests or services.
  
• It is acceptable for an AHP to order a test provided the individual ordering the test or procedure is acting within the scope of any license, certificate, or other legal credential authorizing practice in the state of North Carolina and within the guidelines regulating the practice.
  
• Orders of AHP's do not need to be countersigned provided that the individual ordering the test or procedure is acting within the scope of any license, certificate, or other legal credential authorizing practice in the state of North Carolina.
  
• The facility's medical staff bylaws and/or rules and regulations define who can accept and document verbal orders.
  
• The facility's medical staff bylaws and/or rules and regulations define who can relay verbal orders and are based upon state law defining who is licensed to order such tests or services.
  
• Physician or AHP authentication must be requested within 24 hours. Facilities may code and bill the account without an authenticated order; however, the order must eventually be authenticated. Authentication timeliness is defined by medical staff bylaws and/or rules and regulations and enforced by hospital policy and procedure.
  
• A standardized laboratory requisition form has been developed and should be used for outpatient laboratory services.
  
• Order sheets and "Super Bills" used by the emergency department and outpatient clinics will provide information needed to order and bill procedures according to the Medicare, Medicaid guidelines.
  
• All requisitions and order sheets will list only Medicare approved tests and panels. Components of all panels will be identified and orderable separately, to facilitate ordering of only those tests that are deemed medically necessary for the treatment and diagnosis of the patient.
  
• Medical Necessity Guidelines will be followed according to Medicare Guidelines which can be found in the NC Medicare Web Site at medicare, and NHRMC will only perform and charge for tests or services which have been ordered by a Qualified Individual. The following outlines the required documentation to support complete test or service orders, coding and billing of outpatient services. Each category listed below (Test or Service Orders, Coding, Billing) is mutually exclusive.

TEST ORDERS:
The following elements are needed to support the performance and charging of a test or service. Please note all elements need not be in the same document, but may be found in many areas.

• Patient's full name,including maiden name, if applicable
  
• Patient's Date of Birth
  
• Patient's Sex
  
• Reason for ordering test or service (i.e., diagnosis, sign, symptom, ICD-9-CM)
  
• Test(s) requested, be specific
  
• Given only by authorized Physician or AHP (first and last name of ordering individual must be provided).
  
• Received only by Qualified Individual
  
• Name of Physician or AHP ordering test (first and last name of ordering individual must be provided).
  
• Complete Address of Physician or AHP
  
• Phone Number, including area code, of Physician or AHP
  
• Physician or AHP authentication (required for physicians not on NHRMC staff)
  
• Current dates - date order given, date/time order entered into patient record and date/time of authentication by responsible practitioner.
  

BILLING:
The following list represents additional elements required to submit a bill for payment of a test.

• Patient's Social Security Number
  
• Patient demographics
  
• Patient's insurance information

 

DEFINITIONS:
Authentication: Way for an author to validate his or her own entry in a document. Methods may include written signatures, faxed signatures or computer "signatures" depending on state law, and medical staff bylaws and/or rules and regulations. Only the physician or AHP ordering the test or service may perform authentication. Authentication must appear on all copies of request or order.

AHP: Any non-physician practitioner permitted by law to provide care and services within the scope of the individual’s license and consistent with individually granted clinical privileges by the facility’s Board of Trustees. For example, certified nurse-midwives, certified registered nurse anesthetists, clinical psychologists, clinical social workers, physician assistants, nurse practitioners, and clinical nurse specialists.

Qualified Individuals: Those persons qualified by specific state rules, regulations and facility medical staff bylaws and/or rules and regulations to accept orders for outpatient tests or services.

 

  REFERENCES:

  Health Information Management, Revised by The American Health Information Management Association (1994) Tenth Edition
  Attorneys’ Textbook of Medicine, Third Edition (11/84)
  Medicare Intermediary Manual 3920.1; 3660.7
  Medicare Hospital Manual 451
  Medicare Carrier’s Manual 2050.2
  State Operations Manual – Tag # A102-A104
  42 CFR 482.23; 482.24; 482.26b.4
  JCAHO IM 7.7; 7.8
  JCAHO MS 2.5
  Licensure and Certification Policy, QM.002