Jamie Posted Fri 24th of February, 2017 18:26:47 PM
Is it necessary to have a provider write an order for labs or x-rays, if they have documentation of results in dictation? I just don't want to be querying the provider if it is not necessary.
Ex: PT came in and had an o/v and finger xray done. Provider wrote up dictation and noted X-ray: Normal.
Billing for 99213 & 73140. Do we need an order for the x-ray? since the provider notated the results in the dictation? I know an order and results are two diff things but if it's not required to have an order then we don't want to be query the provider if we do not have to.
SuperCoder Answered Mon 27th of February, 2017 02:39:42 AM
Greetings from SuperCoder.com!
Thanks for your question.
If you bill laboratory services to Medicare, you must obtain the treating physician’s signed order (or progress note to support intent to order) and documentation to support medical necessity for the ordered service(s).
Providers who order diagnostic services must also maintain documentation of the order and medical necessity of the service(s) in the patient’s medical record.
If an order for tests is unsigned, you may submit progress notes showing intent to order the tests. The progress notes must specify what tests you ordered. A note stating “Ordering Lab” is not sufficient. If the orders and the progress notes are unsigned, your facility or practice will be assessed an error, which may involve recoupment of an overpayment.
Please feel free to write if you have any concern or questions.