Question:

When physicians submit prescription pad orders for outpatients and write “CBC” with no signs, symptoms, or ICD-10 information, the registration staff will be in a quandary as to which test to select and what to do about medical necessity. Does the doctor want a differential? Should they ask the patient for diagnostic information?

Answer:

The correct step in such a case would be to contact the ordering physician for clarification. Let the physician select the extent of service and provide the reason for the test. The lesson here is to keep it simple. Using check-off style outpatient requisitions will help your registration staff by removing them from the decision-making process, and it will restrict the use of prescription pad orders. Many orders will be transmitted electronically through a portal, electronic record, or interface. Regardless of whether the order is written on paper or submitted electronically, the laboratory must take appropriate steps to ensure that complete and accurate information is received from the ordering provider. Note that protocols are not accepted by Medicare as orders.

This question was answered in our Coding Essentials for Laboratories. For more hot topics relating to laboratory services, please visit our store or call us at 1.800.252.1578, ext. 2.

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