Make Sure Orders are Compliant

by Valerie A. Rinkle, MPA

Orders for services are a vital component to ensure coverage by Medicare. With the advent of computerized provider order entry (CPOE), it is important to review order templates in the EMR and the resulting order produced or printed in the formal legal medical record to ensure they meet requirements. Due to increased audit scrutiny, including this week’s resumption of inpatient status reviews by QIOs, it is vital to “audit proof” your organization’s EMR and legal medical record so that the orders substantiate coverage of services.

The QIOs are auditing to ensure validity of inpatient orders as well as to ensure that the case meets the benchmark for at least two nights of hospital-level care. These determinations are dependent on valid orders.

CMS has published numerous resources on orders for both outpatient services and inpatient admission.  Requirements for orders vary based on the type of services such as diagnostic laboratory services, other diagnostic tests, inpatient admission, outpatient admission, observation services, and others.  A good resource is the following article, “Complying With Medical Record Documentation Requirements”.

Orders must be signed or otherwise legitimately authenticated. Transmittal 327 contains detailed information concerning physician signatures/authentication.

Elements of a Valid Order

To be considered a valid order, several elements must be present. Elements required in statute or regulations by Medicare are bolded.  

• Patient name and best practice would be another identifier such as Date of Birth
• Date of the order
• Test or service ordered by name and best practice would be to include the HCPCS/CPT of the test
• Clinical indication/justification/reason for the test in medical terminology (e.g., sign, symptom, diagnosis) and/or ICD-10-CM codes
• Name of ordering provider who must be a treating provider meaning he or she has conducted an exam and intends to use the results of the test in continued treatment of the patient
• Authentication of ordering provider (signature or valid electronic signature and credentials)
• If a drug is ordered, the drug name, dosage, route of administration, and rate for infusions

Format of Orders

There is no requirement regarding the format of orders. For providers not linked to a hospital’s EMR, orders may continue to be delivered in writing or via facsimile. Often, the beginning of the work flow for the hospital EMR is to transcribe the order into the EMR for the patient. If this step occurs, it is vitally important that the original order be scanned and linked to the EMR to substantiate the information transcribed. What if the staff transcribing the order incorrectly enters the information? What if the test is not logical or valid for the indication? The clinical staff providing the service should have the ability to view the original order and make any corrections or obtain an updated order as appropriate. Auditors expect to see the original order. If the order is not entered via CPOE, there is no documentation in the EMR regarding the origination of the order, which is why the scanning of the order along with the transcription step for a written or faxed order is so crucial.

ED Protocols

What about testing initiated via protocol in the emergency department (ED) prior to the patient being seen by the treating provider? Protocols need to be vetted very carefully with the medical staff and with the MAC in your region. Typically, the orders are initiated as a verbal order in the EMR based on the presenting signs and symptoms of the patient. Once the patient is seen by the provider and the results of the tests are used by the provider in treating the patient, the verbal order is authenticated by the treating ED provider in the EMR. With this workflow, the requirements for orders are met. The concern with this workflow is whether the hospital has controls in place for patients who leave without being seen (LWBS) by the provider and for tests the provider does not agree were needed.