Medicare: No signature required for ordering tests paid on fee schedule

Why This Topic Matters

Proper documentation of diagnostic test orders is a common compliance issue, especially when records are split between ordering and testing locations. Understanding the Medicare policy update helps practices align chart documentation with current federal guidance.

Article Sections

1. Order documentation and communication methods

   This section describes how Medicare recognizes a diagnostic test order and the general ways it may be communicated between the treating practitioner and the testing facility.

2. Recordkeeping requirements for the order

   This section covers where supporting documentation should be retained and emphasizes the need for documentation in both participating medical records.

3. CMS update to signature requirements

   This section summarizes the Medicare manual update and the policy change related to signature expectations for certain diagnostic tests and related fee-schedule-paid services.

4. Physician documentation of intent

   This section addresses the need for the medical record to reflect the practitioner’s intent that the test be performed.