The use of the term, "standing orders", in Medicare is problematic due to its diverse meanings and usages, not all of which are covered by Medicare. "Standing orders" may be understood to describe both recurring orders specific to the care of an individual patient and as routine orders for services delivered to a population of patients. Standing orders may be utilized for non-laboratory services if they met the definition of recurring orders, not routine orders. Standing orders may be used for laboratory tests ONLY if several conditions are met.
Recurring Orders Medicare may reimburse "standing orders" for physician services for an
individual patient's treatment. An example may be: "Evaluate this patient's wound on a weekly basis for signs of infection or vascular compromise prior to dressing change or referral for physician evaluation times three." The medical record must demonstrate that the order is medically reasonable and necessary.
Routine Orders These types of orders prescribe those services and treatments that are to be applied to patients who have the same or similar medical condition(s). These "routine", "protocol", or "standing orders" are based on an assessment of the impact of a given condition in the population of patients with that condition (medical illness or injury) and are broadly applied to those patients.
Medicare does not accept such "standing orders" as supporting medical necessity for the individual patient as is required by law. Medicare defines any order(s) that does not specifically address an individual patient's unique medical status, illness or injury, as not reasonable and necessary and services consequent to population-based or condition-based orders are not reimbursable.
Treatment Protocols are not necessarily the subject of this routine orders statement. The use of chemotherapeutic drug protocols, for example, that suggest drugs, dosage ranges, frequency and/or duration may be reimbursable since these protocols are individualized to the individual patient.
Laboratory Orders Medicare requires that lab tests be individually and specifically ordered for the patient, reviewed, and action taken by the
treating physician. Automatic, routine, or generic standing orders for lab tests, such as those pre-printed for use with patients undergoing a procedure or admission (whether for all such patients or all those treated by a specific practitioner) are not allowed under Medicare. However, in some circumstances, a standing order for a recurring lab test that is specific to the needs of an individual patient may be reimbursable. (See requirements below.) In addition, preprinted or electronic lists of
potential orders are permitted if the provider
individually affirms, defines, or otherwise modifies each component as appropriate for an individual patient's clinical circumstances.
Standing orders for recurring diagnostic tests may be appropriate when all of the following conditions are met:
1. Each ordered test must be appropriate for the known or suspected diagnosis.
2. Each ordered test must be appropriate for the individual patient's clinical circumstances.
3. Each test performed must be necessary for the individual patient's management.
4. The frequency of repeated testing must not be greater than medically necessary.
5. The number of repeated studies must not be greater than medically necessary.
6. The diagnosis must be indicated for each test with sufficient clarity to permit accurate ICD-9-CM coding to the highest level of specificity.
7. The order for the recurring test must be renewed at least annually or sooner if required by state law or the patient's clinical circumstances.
8. The treating physician must review each test's result, making any indicated adjustments in frequency and number of repeated studies.
9. Documentation must demonstrate that all lab tests were reviewed and appropriate clinical action taken.
Examples of appropriate, recurring diagnostic tests under Medicare include:
- Serial studies necessary to establish or characterize a diagnosis, e.g., repeated cardiac enzymes necessary for a patient with presenting symptoms suggestive of acute ischemia.
- Serial studies as an essential and well-established part of quality medical care that help assure medically necessary monitoring of drugs with a high potential for adverse reactions, e.g., prothrombin times for a patient on chronic warfarin, aminoglycoside levels where "peak" and "trough" levels are needed, serial measures of renal or hepatic function in a patient on a nephrotoxic or hepatotoxic drug, respectively, or hematocrits in a patient on an erythrotoxic drug.
Note: In relation to blood glucose testing, CMS has specifically instructed in CR5443, Transmittal 258 dated 12/22/06, under Technical Refinements to the Clinical Laboratory Fee Schedule:
Medicare separately pays for a blood glucose test only when the service meets all of the conditions of payment for a test payable under the clinical laboratory fee schedule including that the test must be ordered by the physician who is treating the beneficiary and the physician must use the results in the management of the beneficiary's specific medical condition. Our regulation states that for payment to be made for a blood glucose test under Medicare Part B, a physician must certify that each test is medically necessary and that a standing order for many tests over a time period is not sufficient documentation. Payment for nursing care glucose monitoring is encompassed under Medicare Part A and other payment methods. In summary, reimbursement of each lab test provided under a standing order for a recurring or serial evaluation is subject to medical necessity review. All such orders must be written for a specific patient, and each instance of the test must be necessary. Each result must be reviewed with appropriate action taken by the treating physician including any appropriate change in the frequency or duration of testing.
Effective Immediately
Sources:
Internet Only Manual (IOM), 100-2, Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, §20.5 D. Services That Are Not Covered as Outpatient Observation
IOM. 100-4, Medicare Claims Processing Manual, Chapter 12 §30.6.10 - I. Examples That Do Not Meet the Criteria for Consultation Services
IOM, 100-4, Medicare Claims Processing Manual, Chapter 30 Financial Liability Protection, §50.7.1 - Exception for Repetitive Notices (Rev. 1, 10-01-03)
IOM, 100-4, Medicare Claims Processing Manual, Chapter 30 Financial Liability Protection, §50.7.6 - ABN Standards for Services in Skilled Nursing Facilities (SNFs) (Rev. 1, 10-01-03)
NCD for Hospital and Skilled Nursing Facility Admission Diagnostic Procedures (70.5); Publication Number 100-3; Manual Section Number 70.5; Version Number 1; Effective Date of this Version 9/1/1979 Federal Register/Vol. 163/Aug., 24, 1998, Office of Inspector General Publication of OIG Compliance Program Guidance for Clinical Laboratories
CMS Manual System, Pub 100-20 One-Time Notification; Transmittal 258, CR5443, dated 12/22/06, effective 1/01/07, p. 12.
42 CFR §410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
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