Kaidachi
Contributor
Hi all,
I’m looking for some guidance or confirmation on CMS’s expectations when it comes to test ordering in the Emergency Department.
We’ve been running into a pattern where one ED provider orders diagnostic tests (labs, imaging, etc.) based solely on the patient’s sign-in complaint and triage notes, before the patient is ever seen, and then a different provider evaluates the patient later in the visit. Sometimes the patient even leaves AMA before any provider interaction happens at all.
Naturally, this is creating headaches for coding and billing (and likely compliance), especially when there’s no documentation from the ordering provider.
The evaluating provider will include the test results in their documentation but doesn’t always include any medical rationale for those tests. (essentially rendering those tests as not medically necessary/unbillable)
I’ve referenced 42 CFR §410.32 and CMS Program Integrity Manual Ch. 6 §6.9.1, which clearly state:
All diagnostic tests must be ordered by the treating physician—meaning the provider managing the patient’s care. Tests not ordered by the treating physician are not considered reasonable and necessary.
My interpretation is:
Is anyone else running into this? How are you managing workflows where multiple ED providers are involved in a single patient encounter? Have you found a compliant way to handle standing orders without risking denials due to documentation or timing gaps? I also worry about unnecessary tests that will ultimately result in a medical necessity denial.
I’m looking for some guidance or confirmation on CMS’s expectations when it comes to test ordering in the Emergency Department.
We’ve been running into a pattern where one ED provider orders diagnostic tests (labs, imaging, etc.) based solely on the patient’s sign-in complaint and triage notes, before the patient is ever seen, and then a different provider evaluates the patient later in the visit. Sometimes the patient even leaves AMA before any provider interaction happens at all.
Naturally, this is creating headaches for coding and billing (and likely compliance), especially when there’s no documentation from the ordering provider.
The evaluating provider will include the test results in their documentation but doesn’t always include any medical rationale for those tests. (essentially rendering those tests as not medically necessary/unbillable)
I’ve referenced 42 CFR §410.32 and CMS Program Integrity Manual Ch. 6 §6.9.1, which clearly state:
All diagnostic tests must be ordered by the treating physician—meaning the provider managing the patient’s care. Tests not ordered by the treating physician are not considered reasonable and necessary.
My interpretation is:
- Triage review alone is not enough to justify test ordering.
- The provider ordering the test must be the same provider who evaluates the patient, unless it’s an emergent situation (e.g., trauma, stroke), in which case documentation must clearly support that urgency.
Is anyone else running into this? How are you managing workflows where multiple ED providers are involved in a single patient encounter? Have you found a compliant way to handle standing orders without risking denials due to documentation or timing gaps? I also worry about unnecessary tests that will ultimately result in a medical necessity denial.