Twenty-nine healthcare organizations, including the American Hospital Association (AHA), sent CMS a letter December 3 opposing what they termed the "redundant and burdensome" signature requirement that CMS announced in the 2011 Medicare Physician Fee Schedule final rule, published November 29. The AHA coalition asked CMS to delay implementation until January 1, 2012.
Instead of a year-long delay, CMS announced on its website that it is concerned that some physicians, non-physician practitioners (NPP), and clinical diagnostic laboratories were unaware of or did not understand the new policy. As a result, CMS will spend the first quarter of 2011 educating providers. "Once our first quarter of 2011 educational campaign is fully underway, CMS will expect requisitions to be signed," CMS noted in its announcement.
The biggest benefit for providers is they will now have more time to educate their medical staff and other facilities, such as nursing homes, says Patti Reisinger, RHIT, CCS, HIM Director at Community Medical Center in Missoula, MT.
The delay also provides facilities with additional time to re-develop forms. Reisinger spoke with a colleague at another facility who is currently revising lab requisitions and orders to include the physician's name and some other shortcuts for physicians.
"My initial take was, 'Isn't it nice that CMS is recognizing that folks may need more time to adjust to major policy changes,'" says Jugna Shah, MPH, president of Nimitt Consulting in Washington, DC. "On the one hand, it seems reasonable that CMS would want to give providers additional time to prepare for this sort of change, yet it's also curious since this is out of the ordinary for CMS."
So what else might be behind the delay?
Shah thinks one reason may be the ongoing pressure from AHA and other organizations to repeal the requirement altogether. "If CMS thinks it might have to repeal this, then maybe the agency realizes that it shouldn't implement it now just to have providers go back to the way things were," she says.
Requisition or order?
CMS is adamant about requiring all lab requisitions to be signed if the lab receives them, regardless of whether a signed order is on file at the lab or in the physician's office, says Debbie Mackaman, RHIA, CHCO, Medicare Boot Camp® Instructor for HCPro, Inc, in Danvers, MA. "CMS' purpose is to reduce confusion on signatures that are required for orders–basically when is an order a requisition and vice versa."
Part of the problem that CMS seems to be trying to resolve with the requirement that all requisitions be signed is the location of signed orders. A signed order is often on file at the physician's office and not readily available to the hospital that performs the lab service based on a requisition which, to date, has not required a signature, Shah says. If the hospital lab had to produce a signed order to justify billing for the lab test, it may run into problems; a signed requisition can serve as the order in these situations.
CMS defines an order as a communication from the treating physician or practitioner requesting that a lab perform a diagnostic test for a beneficiary. Orders may be conveyed via:
- A written document signed by the treating physician/practitioner that is hand delivered, mailed, or faxed to the treating facility
- Telephone call
- E-mail or other electronic means
CMS says a requisition is the actual paperwork, such as a form, that the physician provides the clinical diagnostic laboratory to identify the test or tests he or she wants performed. The requisition may contain patient information, billing information, specimen information, and test selection. CMS stated in the final rule that a requisition signed by a physician may serve as an order, to minimize confusion about signed orders vs. unsigned requisitions going forward.
"I have seen many facilities combine their order and requisition form into one document, so basically the requisition is always signed because it is also the order," Mackaman says.
Take advantage of the delay
During the implementation delay, reach out to your medical staff and educate them on the CMS regulations and why these are important for them, Reisinger says. Consider revising your requisition forms to include a prompt for the physician to sign the requisition. Reach out to nursing homes, home health organizations, and other agencies your facility works with, and educate them as well.
"This delay is certainly a benefit for hospitals so they can take time now to work with the different providers from whom they receive requisitions for lab services," says Shah. "When CMS releases educational material on this issue, hospitals may find it easier to have a concrete dialogue about the CMS requirement with its physicians and NPP partners."
Looking forward
Reisinger wasn't surprised by the delay, in part because of the letter sent by the AHA and others. "The onus is on us to make sure the changes are in place," Reisinger says. "We're going to be the ones seeing the denials come through. We needed the time, so I'm very grateful, but I'm not surprised."
Don't be surprised if the rule is delayed again, Reisinger says. "It is going to be a huge burden for hospitals." Hospitals are unlikely to turn away patients because the physician didn't sign the requisition, but if CMS does not delay it again, the question of the financial impact will be very interesting, Reisinger says.
"I don't think that CMS will overturn this rule this year, but may modify it somewhat in the coming rulemaking process for 2012," Mackaman adds.
Another question that arises is how diligent and aggressive CMS will be in reviewing records for signatures. "I don't know if they will take it as far as the RACs or whether they will be focused reviews," Reisinger says. "There's a lot of burden placed on facilities to make sure we're in compliance with this and we don't get the denial of payment."
Providers are basically in a wait-and-see mode now, Shah says. The outreach material could help predict which way things will go. "If the material is forthcoming, we can anticipate that this delay will be over at some point," Shah says. "If it's not forthcoming, it's quite possible that this could be delayed further and further and quite possibly repealed altogether based on the opposition CMS has received and continues to receive."