Recognizing the Meaning of "Standing Orders"
Medicare will consider payment for appropriately documented covered services that are reasonable and necessary for the beneficiary, given his/her clinical condition. Medical necessity is the driving force for the payment of any Medicare service. If a service is not medically necessary, it cannot be paid by Medicare. Providers need be cognizant of the various meanings represented by use of the term "standing orders." Some understand this to mean recurring orders specific to the care of an individual patient, while others understand this as routine orders for services delivered to a population of patients. The following can help you understand the various uses of "standing 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.
For physician services, Medicare may reimburse "standing orders" that are specific to an individual patient's treatment. For example: the standing order "Evaluate this patient's decubitus ulcer on a daily basis for signs of infection i.e. drainage, odor, size and staging prior to changing dressing."
Reimbursement of tests or services 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 or service 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.
Treatment protocols may be reimbursable since these protocols are individualized to each patient. For example, the use of chemotherapeutic drug protocols, that suggest drugs, dosage ranges, frequency and/or duration specifically ordered for an individual patient.
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.) Preprinted orders are not covered by Medicare. However, 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:
- Each ordered test must be appropriate and necessary for the individual patient's clinical circumstances.
- The frequency and number of repeated testing must not be greater than medically necessary.
- The diagnosis must be indicated for each test with sufficient clarity to permit accurate ICD-9-CM coding to the highest level of specificity.
- The treating physician must review each test's result, making any indicated adjustments in frequency and number of repeated studies.
- All lab tests must be reviewed and documentation must support that the appropriate clinical action was taken.
Examples of appropriate, recurring diagnostic tests under Medicare include:
- Repeat cardiac enzymes to rule out acute ischemia.
- Prothrombin times for a patient on chronic warfarin.
In relation to blood glucose monitoring, CMS has specific instructions in Change Request (CR) 5443:
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.
Standing Orders for Consultation
Standing orders for consultations for Medicare beneficiaries admitted to a hospital, observation unit, or a nursing facility are not allowed. There must be medical necessity for any such consultation.