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Wiki Laboratory Orders

J

JJOHN0312

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Our hospital facility is looking into a coding policy that implements coding of of labs without a signed physician order. Is this compliant? Is there a situation where this would apply/be compliant?

All the research I do, seems like it is not real clear.

Thank you,

Josie
 
Signed orders are required for most diagnostic services. CMS will accept a signed progress note showing the intent to order as a substitute for the order itself, but there does need to be a way to show that the provider authenticated the order.

Here's a good reference regarding signature requirements:

https://www.cms.gov/Outreach-and-Ed...gnature_Requirements_Fact_Sheet_ICN905364.pdf.

Also, here is a link to a reference on documentation requirements for labs - there are additional links at the end for more information:

https://www.cms.gov/Outreach-and-Ed...Downloads/LabServices-ICN909221-Text-Only.pdf

Hope this helps some.
 
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