Physician Signature Clarification
During reviews performed by the Comprehensive Error Rate Testing (CERT) contractor, concerns have emerged involving the requirements for physician signatures on orders for diagnostic tests. The following information is intended to clarify the requirements for providers.
IOM Pub 100-2, Ch 15, sect 80.6 et sub. concerning physician's signatures reads (in part) as follows:
An order may be delivered via the following forms of communication:
A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility; NOTE: No signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services...
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records. While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed.
Keep in mind that while the lab request itself does not require a signature, there must be a signature in at least one of two places – either on the office note in which the intent to order the test was clearly documented, or on the requisition or lab order slip.
Remember, providers have the same appeal rights for CERT initiated denials as they do for denials initiated through CGS. All of the same Medicare guidelines apply, including those regarding the 120-day time frame allowed for an appeal (redetermination).
The Redetermination (Appeal) Request Form can be found on the Part B Forms Page under the General Forms heading.