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Requisition signed order

welcome to this tutorial on ordered referred and prescribed services the information given in this training is correct as of July 2020 the most current information related to this topic can be found on the nuridium and CMS websites at the links listed on this slide claims that are the result of an order or a referral must contain the national provider identifier or NPI and the name of the ordering a referring provider and the provider must be in the provider enrollment chain and ownership system or Pecos the Affordable Care Act requires physicians and eligible non-physician practitioners or NPP's to enroll in Medicare to order or refer items or services for Medicare beneficiaries even if they are not sending claims for their services listed here are the types of services provided that are the result of an order or referral physicians and non-physicians partners who order and refer must be enrolled in Medicare in either an approved or an opt-out status licensed in the state they are applying and enrolled in a specialty type eligible to order and refer listed on this slide are those professionals eligible to order and refer services Medicare will only reimburse for specific items or services when ordered or referred by providers or suppliers authorized by Medicare statute and regulation to do so a claim will deny as non-covered if billed with an ordering/referring physician listed on this slide based on the fact that neither statute nor regulation allows the coverage of certain services when ordered or referred by any of the specialties listed here home health agencies hhas and optometrists have ordering and referring limitations home health agency services may only be ordered or referred by a doctor of medicine MD doctor of Osteopathic do or doctor of Podiatric medicine DPM claims for HHA services ordered by any other practitioner specialty will be denied optometrists may only order and refer durable medical equipment prosthetics orthotics and supplies and laboratory and x-ray services payable under Medicare Part B CMS follows individual state laws the teaching admitting or attending physicians name and NPI can be listed on the claim as the ordering or referring provider as long as that provider is of a specialty eligible to refer and has a current enrollment record in Pecos for unlicensed interns and residents the claim needs to have the teaching physicians name and NPI in item 17 the state licensed residents may enroll in Medicare to order and refer the claim needs to list the residents NPI in item 17 certain physicians and other practitioners are permitted by statute to opt out of the Medicare program and still order items or services for Medicare beneficiaries in order to opt out providers must submit and opt out affidavit with Medicare and must keep a private contract with all beneficiaries on file for each two-year period here is a list of providers who are eligible and not eligible to opt out of Medicare a signature is not required on orders for clinical diagnostic tests or physician pathology if the order for the clinical diagnostic tests is unsigned there must be medical documentation such as a progress note by the treating physician that they intended the clinical diagnostic tests be performed the documentation must show the intent for the tests to be performed and must be authenticated by the author the order may request an additional diagnostic test if the result of the initial diagnostic tests ordered indicates another test may be needed for example if test X is negative then perform test y all diagnostic services require a physician order or progress note that supports intent an unsigned order or requisition will not be considered during a review a signature attestation statement is not acceptable for unsigned orders and requisitions if progress notes are used to support intents the specific tests requested must be clearly documented if the progress note is unsigned a signature attestation should be completed by the ordering provider and submitted with records orders can be delivered in several ways examples of acceptable documentation are a signed order or a signed requisition by the physician an order or requisition that is not signed by the physician does not support the physicians intent for the tests to be performed or a notation in the patient's medical record documenting the need for or the intent to obtain a specific test signed by the physician a verbal or telephone order is acceptable this must be documented at both the treating physicians office and the testing facility and placed in the beneficiary's medical record the order must be signed within the timeframe specified by the state or an email from the physician that may be verified as coming from the physician tests not ordered by the physician who is treating the beneficiary are not reimbursable although no signature is required on an order for a clinical diagnostic test paid on the laboratory fee schedule the physician must clearly document and sign in the medical record his or her intent to have the test performed the entity providing the laboratory test result must maintain all documentation including the physician order and the test findings to support the claim submitted the medical record must be complete and legible it must also include detailed information such as documentation to support the physician who referred the patient the physician ordering the services what the intent was and how it was decided to perform the treatments as well as documentation to support the billing or rendering provider who provided the service medical records must include detailed information such as the reason for the encounter relevant history findings test results and dates of service assessment and impression of diagnosis a clear concise reflection of the patient's condition the plan of care with a date and legible identity of the observer if drugs are ordered the administration record must include dosage where it was given and the administration route include test results as well as an advanced beneficiary notice of non coverage or ABN if one was signed by the patient because Medicare will not pay for the service or item due to medical necessity the top reasons why claims deny under a review are medical documentation does not support the services provided the intent for the specific test that was ordered is missing there is no legible signature or there is a lack of signature log or attestation statement which needs to be included with submitted documents also commonly seen is no valid diagnosis documented in the medical record a provider is at risk of monies being recouped due to not responding to record requests Medicare only pays for services that are reasonable and necessary to diagnose or treat the patient while Medicare rules may make exceptions or specifications for certain services medical necessity is what decides whether most Medicare services may or may not pay national coverage determinations or NCDs are policies that define the extent to which Medicare will cover specific services procedures or technologies on a national basis the coverage guidance section gives coverage indications limitation of coverage and medical necessity guidelines these conditions need to be met in order for it to be a medically necessary service the local coverage determination or LCD may list indications of conditions that are not deemed medically necessary and reasonable some also lists diagnosis codes that support medical necessity the coding guidelines section gives further detail on how claims should be submitted some policies may have a primary and secondary diagnosis code that is needed some policies will indicate which diagnosis codes are payable with certain CPT codes it may also indicate diagnosis codes that do not support medical necessity for further information regarding ordering and referring providers refer to these resources for laboratory services a helpful resource is this Medicare Learning Network or mln factsheet thank you for taking the time to listen to our tutorial continue your learning experience by referring to additional recordings available on the Meridian website or YouTube channel