Orthopedics "protocol"

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Joined: Fri Sep 19, 2014 9:12 am

Tue Apr 28, 2015 3:07 pm

Hello, a patient is scheduled for an appointment with the orthopedic surgeon to evaluate knee pain and is told the physician's protocol is to have xrays prior to being seen. If the patient has not been seen, where is the medical necessity for the ordering of xrays? There is obviously no treatment plan in place. I'm seeing this over and over again and wonder if I am missing something? It just doesn't smell right to me. Thanks for any help.
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Fri May 01, 2015 2:06 pm

It would seem the medical necessity is the knee pain, no?
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Fri May 01, 2015 2:34 pm

But if a patient self-refers to the Ortho office and has never seen a physician there, how can the medical necessity for xrays be determined? Cart before the horse situation. Seems to me the patient should at least be seen and evaluated before any diagnostics are ordered. I'm just looking for some documentation on this. Thanks for the reply.
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Fri Jun 19, 2015 4:20 pm

If they have "standing orders" this could fall pursuant to this, and therefore an acceptable practice.
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Tue Nov 17, 2015 4:42 pm

Hi. I'm curious about this, too. I thought Medicare did not accept "standing orders" for supporting medical necessity for diagnostics.

I have heard a similar scenario described to me by someone at an Ob/Gyn office where the nurse was collecting and completing a urinalysis on every single patient who came in, prior to the patient seeing the physician. This seemed at face value to possibly represent a nurse acting outside her scope of practice, but are you saying that a "standing order" by the physician would cover that scenario as well? Or does the "standing order" need to be specific to a particular symptom set, such as "standing order for urinalysis for all patients complaining of dysuria and/or low back pain"? Thank you for any additional info you can provide.
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Mon Nov 23, 2015 9:53 am

Your question has been answered by Senior Consultant Betty Stump:

CMS has issued notice that the use of routine 'standing orders' not meeting a specified set of criteria are deemed not medically necessary. Noridian defines the acceptable requirements for standing orders as.
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.

Both Noridian and WPS have clear policies located on their website to clarify; other MAC's may have similar policies noted as well. The WPS policy is as follows:

Routine Orders
Routine orders are orders for those services and treatments that are applied to patients who have the same or similar medical condition(s). These frequently called "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 widely applied to those patients. Medicare defines any order(s) that does not specifically address an individual patient's unique illness, injury or medical status, as not reasonable and necessary. As is required by law, Medicare does not accept such "standing orders" as supporting medical necessity for the individual patient. Services related to population-based or condition-based orders are not reimbursable.
Noridian policy: (located:https://www.noridianmedicare.com/cgi-bi ... b_viewnews)
WPS policy: (located: http://www.wpsmedicare.com/j8macpartb/d ... ders.shtml)
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Wed Jun 22, 2016 1:36 pm

Do you know if Novitas has a policy on "standing orders"? I have searched all morning and cannot find a policy on their website. The scenario I am curious about, is audiological testing protocol for patients scheduling with chronic ear issues. I would love to put this subject to rest and allow the physicians to have the results of the testing available at the time they see the patient.
Shannon DeConda
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Tue Jul 19, 2016 2:26 pm

Well, not specifically to your topic.
I was able to find that Novitas pointed toward standing orders in the following link regarding urine drug screens, and my personal opinion is that if they feel this way about urine drug screen standing orders, I'm guess it would be the same for all standing orders.
Standing orders may result in testing that is not individualized, not used in the management of the patient’s specific medical condition and not “reasonable and necessary.”

This can be found at:
http://www.novitas-solutions.com/webcen ... 4182213810#!
Thank you,
Founder & President of NAMAS

Disclaimer: NAMAS cannot be held liable for any advice given that could have had a variable answer based on additional information.
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