| West Virginia Oncology Society |
Payers say we were forewarned and now reality is setting in. Over the past number of months many of
our oncology practices throughout the country have been audited by Medicare, Blue Cross and other
private payers with recoveries amounting to hundreds of thousands of dollars! The top three negative
audit findings are:
1. No ORDER for the drug/service rendered (examples of actual take backs below)
a. No order for the drug &/or administration…
i. take back payment!
b. No order for the port flush….
i. take back payment!
c. No order for Kytril or Benadryl (pre-meds)…..
i. take back payment for the drug and administration!
d. No co-signature of physician verbal order…
i. take back payment for the drug and administration!
2. Administration coding outside the AMA guidelines
a. Example: Billing for 2 hours for administration services not exceeding 30 minute add’l
hour requirement
3. No documentation of waste in the patient’s medical record
Suddenly, Medicare and many other payers are sending information to providers about their
requirements for orders and physician signatures. With the recent updates and increase in the number
of audits, the compliance with the requirements has become a main concern for many of our practices.
Now is the time to review your patient records to be sure you comply with the requirements.
Below you will find some specific information related to orders:
Elements of an Order
• Medication
• Dose
• Route
• Frequency
• Length of treatment
• Date
• Physician Signature
Verbal Orders Guidelines
• Requirements:
Name of physician giving the order
Date order is taken
Elements of a written order
Staff member signature or initials
Staff member’s credentials
Note: “Verbal orders that are written, dated, and signed or initialed by a non-
physician health care professional or other staff must also be dated and signed or
initialed by the physician.”
Use of Protocols and Standing Orders
• There must be a reference in the physician’s orders to identify the specific protocol or
standing order.
• The order must indicate the link between the patient’s therapy and the protocol/standing
order.
• Any deviations of the protocol/standing order must be clearly indicated in the written order.
• All written protocols and standing orders used by the provider must be reviewed, dated
and signed by the physician.
Orders and Palmetto GBA
This past Medicare Advisory published by Palmetto Medicare showed results of CERT audits and warned
us to make sure we comply or they will recover payments:
CERT Order Denials
Take the time to review the information above, payer websites, etc., and audit your practice before
they audit you!
our oncology practices throughout the country have been audited by Medicare, Blue Cross and other
private payers with recoveries amounting to hundreds of thousands of dollars! The top three negative
audit findings are:
1. No ORDER for the drug/service rendered (examples of actual take backs below)
a. No order for the drug &/or administration…
i. take back payment!
b. No order for the port flush….
i. take back payment!
c. No order for Kytril or Benadryl (pre-meds)…..
i. take back payment for the drug and administration!
d. No co-signature of physician verbal order…
i. take back payment for the drug and administration!
2. Administration coding outside the AMA guidelines
a. Example: Billing for 2 hours for administration services not exceeding 30 minute add’l
hour requirement
3. No documentation of waste in the patient’s medical record
Suddenly, Medicare and many other payers are sending information to providers about their
requirements for orders and physician signatures. With the recent updates and increase in the number
of audits, the compliance with the requirements has become a main concern for many of our practices.
Now is the time to review your patient records to be sure you comply with the requirements.
Below you will find some specific information related to orders:
Elements of an Order
• Medication
• Dose
• Route
• Frequency
• Length of treatment
• Date
• Physician Signature
Verbal Orders Guidelines
• Requirements:
Name of physician giving the order
Date order is taken
Elements of a written order
Staff member signature or initials
Staff member’s credentials
Note: “Verbal orders that are written, dated, and signed or initialed by a non-
physician health care professional or other staff must also be dated and signed or
initialed by the physician.”
Use of Protocols and Standing Orders
• There must be a reference in the physician’s orders to identify the specific protocol or
standing order.
• The order must indicate the link between the patient’s therapy and the protocol/standing
order.
• Any deviations of the protocol/standing order must be clearly indicated in the written order.
• All written protocols and standing orders used by the provider must be reviewed, dated
and signed by the physician.
Orders and Palmetto GBA
This past Medicare Advisory published by Palmetto Medicare showed results of CERT audits and warned
us to make sure we comply or they will recover payments:
CERT Order Denials
- Denial Reason, Reason/Remark Code(s)
• Absence of Valid Orders/Requisitions/Documentation of “Intent”
• CO-226: Information from the Billing/Rendering Provider was not provided or was
insufficient/ incomplete
• N455: Missing physician order
Denial Reason, Reason/Remark Code(s)
• Incomplete/Invalid Orders/Requisitions/Documentation of “Intent”
• CO-226: Information from the Billing/Rendering Provider was not provided or was
insufficient/ incomplete
• N456: Incomplete/invalid physician order
Resolution/Resources:
• The CERT Review Contractor assesses errors when there is no evidence of “intent” or
documentation of the request, in accordance with Medicare requirements. As a result, Palmetto
GBA (Ohio/West Virginia) must initiate claim adjustments and recoup any related overpayments
from providers. For denial purposes, these messages will be applied in situations involving
ordering-treating physicians or qualified non-physician practitioners.
• If you received Medicare Remittance Advice notification of these errors and disagree with
the denials, send a written request for a redetermination (Appeal) to Palmetto GBA. A
redetermination is the first level of appeal and must be requested within 120 days of the date
shown on the remittance advice notice of the denied services.
•
• Do not refile the claim. The decision for the denial was based upon CERT’s review of medical
records; therefore, it can only be resolved by filing an Appeal with Palmetto GBA.
• Ohio: http://www.PalmettoGBA.com/boh or West Virginia: http://www.PalmettoGBA.
com/bwv. Go to Resources, select Forms.
• Please clearly indicate ‘CERT’ when completing the redetermination form.
- References
• Ohio: http://www.PalmettoGBA.com/boh or West Virginia: http://www.
PalmettoGBA.com/bwv. Go to ‘CERT,’ select ‘General Information’ and open the
article, ‘CERT Denials Related to Orders for Laboratory & Pathology Testing’
• Please see: Medicare Program Integrity Manual Pub. 100-08, Chapter 3,
Section 3.4.1.2 at http://www.cms.gov/manuals/downloads/pim83c03.pdf and
Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 80.6.1 at http:
//www.cms.gov/manuals/Downloads/bp102c15.pdf
Take the time to review the information above, payer websites, etc., and audit your practice before
they audit you!
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| Physician Office Infusion Therapy AUDITS |
