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January 25, 2018

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Medical Coding News Archives

CMS Clarifies Rules for Diagnostic Test Orders

September 23, 2008:

In a recent transmittal, the Centers for Medicare and Medicaid Services clarified which diagnostic services do not require an order with a physician signature under the Medicare program. The agency went on to note that even for those services, there still must be documentation in both the ordering and performing providers’ records indicating the ordering physician’s intent to have the tests performed.

Basically, CMS states that an order is “a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary.” Orders may be provided in the following formats.

  • A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility. As part of the clarification, CMS indicates that NO signature is required on orders for clinical diagnostic tests that are paid:
    • under the clinicallaboratory fee schedule
    • under the physician fee schedule
    • as physician pathology services
  • A telephone call by the treating physician/practitioner or his/her office to the testing facility. When this method is used, both the treating and ordering providers must clearly document the verbal order in the medical record.
  • An electronic mail by the treating physician/practitioner or his/her office to the testing facility.

Orders may also conditionally request additional diagnostic testing. For example, if a CT reveals X finding, an MRI should be performed or if a laboratory test is negative, perform test Y.


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