Q&A: Ensuring physician orders are compliant

Q: What are the elements of a valid order?

To be considered a valid order, several elements must be present. Elements required by Medicare statutes or regulations are bolded.

• Patient name; best practice would be another identifier such as date of birth
• Date of order
• Test or service ordered by name; best practice would be to include the test’s or service’s Healthcare Common Procedure Coding System (HCPCS) code, including Current Procedural Terminology (CPT®) codes
• Clinical indication/justification/reason for the test in medical terminology (sign, symptom, or diagnosis) and/or ICD-10 codes
• Name of ordering provider, who must be a treating provider, meaning they have an established relationship with the patient and intend to use the results of the test in continued treatment of the patient
• Authentication by ordering provider (signature or valid electronic signature and credentials)
• If a drug is ordered, the drug name, dosage, frequency, route of administration, and infusion rate (if applicable)

Editor’s note: This answer was excerpted from “Don’t forget to validate orders,” in the April 2024 issue of the NAHRI Journal. The NAHRI Journal is a quarterly journal featuring in-depth analysis and expert advice and is an exclusive benefit of NAHRI membership. Not a member? Join today.