Wiki Question regarding orders

[cfitzgibbons]

What components must be on orders, i.e. Diagnosis codes, services needed, etc? I am challenging some information that I feel to be incorrect and I thought ' what better place to come with my dilemma than my fellow coders!'

Thanks for your help.

 

[Sandy Stevens]

The record(s) should clearly state each test and the reason for each test - or it must be easily inferred according to CMS (i.e., medical necessity must be clear) and a valid signature by the ordering physician should be all you need. Are you running into issues that are otherwise?