Are Your Diagnostic Test and Lab Ordering Processes Compliant?

Patients suffering from mental health conditions can frequently resort to self-medicating through drug and/or alcohol abuse. However, not everyone with a mental health condition automatically needs to be screened or tested for drug abuse. There should be a clinical indication or reason for ordering such tests.

One Kentucky psychiatrist found out that this is true the hard way. The psychiatrist allegedly ordered drug testing outside the ordinary course of medical practice without a legitimate medical reason. The psychiatrist admitted that she did not document the results of some of the drug tests and services and failed to use the results in treating her patients. Additionally, the physician admitted that she caused the laboratory to pay her a certain portion of the reimbursements the laboratory received, which caused the Kentucky Medicaid program to pay for services that should not have been paid for. The psychiatrist was sentenced to 36 months of probation and ordered to pay restitution of over $24,000 for ordering drug testing on patients without a legitimate purpose.

This example should drive home the importance of individualized treatment decisions, especially in mental health. Just because something may be common for a specific population of patients does not mean that it should automatically be ordered or performed for all patients in that population. In the case shared earlier, the physician received payment from the laboratory where she ordered the tests. In similar scenarios, the HHS OIG has warned physicians that taking money or gifts “…is not justified by the argument that you would have prescribed that drug or ordered that wheelchair even without a kickback.”^[i]

When it comes to ordering labs or other diagnostic tests, CMS has outlined some very important guidelines regarding clinical documentation. Regarding appropriate documentation, CMS specifically states:^[ii]

• • The physician who treats a patient must order all diagnostic x-rays, diagnostic laboratory tests, and other diagnostic tests for a specific medical problem. The physician uses test results to manage the patient’s specific medical problem and may provide a consultation.
  • The physician should clearly indicate all tests to be performed (for example, “run labs” or “check blood” by itself doesn’t support intent to order) when completing progress notes.
  • Documentation in the patient’s medical record must support the medical necessity for ordering the service(s) per Medicare regulations and applicable Local Coverage Determinations (LCDs). Submit these medical records if they’re requested.

Some of the other Medicare medical documentation requirements include:

• • A signed order or requisition listing the specific test.
  • An authenticated medical record supporting the physician’s intent to order specific tests.
  • Unsigned physician orders or unsigned requisitions alone don’t support physician intent to order.
  • Physicians should sign all orders for diagnostic services to avoid potential denials.

There are exceptions when it comes to signatures, but the burden of proof still rests on the medical documentation. For example, if the signature is missing on a progress note, but the note does support the physician’s intent to order a lab, the ordering physician must complete and submit an attestation statement if the records are requested.

In mental health treatment, laboratory tests are frequently ordered, especially to screen or test patients for drug or alcohol use/abuse. But remember, just because it is common does not mean you can ignore individual determinations of medical necessity for each and every test ordered.

References

• [i] https://oig.hhs.gov/compliance/physician-education/fraud-abuse-laws/
• [ii] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/LabServices-ICN909221-Text-Only.pdf

Download this blog as a PDF, click the button below.