What do I need to document when I refer a patient for an ancillary service or diagnostic procedure?Before an ancillary service or diagnostic procedure can be executed, an 'order' must be communicated from the treating physician/practitioner requesting that the service/procedure be performed for a beneficiary. An order may be delivered via a written document signed by the treating physician/practitioner, which is hand-delivered, mailed, faxed, or e-mailed to the testing facility/department.
Alternatively, a telephone call by the treating physician/practitioner or his/her office to the testing facility/department may be used. If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility/department must document the telephone call in their respective copies of the beneficiary's medical records. While a physician order is not required to be separately signed, the physician must clearly document, in the medical record, his or her intent that the ancillary test or diagnostic procedure be performed.