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Physicians to get relief from Medicare lab paperwork rule

The AMA and groups representing clinical laboratories had urged CMS to rescind a new requirement that doctors sign off on lab tests.

By Charles Fiegl amednews staff — Posted Feb. 28, 2011

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Responding to pressure from the American Medical Association and others, the Centers for Medicare & Medicaid Services has indicated that it will rescind a new Medicare rule requiring physicians to provide their signatures on requisitions for laboratory tests. Doctors had warned that the rule would have created paperwork headaches for medical professionals ordering and fulfilling lab test requests, ultimately having an adverse impact on patient care.

The signature policy has been on the books since Jan. 1, but it was never enforced by the Medicare agency. CMS finalized the rule in its 2011 physician fee schedule in November 2010. However, citing concerns about lack of awareness of the change in the health care industry, the agency delayed enforcement of the policy until April 1.

Lawmakers soon became involved, requesting an additional nine-month enforcement delay. Reps. Michael Burgess, MD (R, Texas) and Bill Pascrell Jr. (D, N.J.) wrote a Feb. 10 letter to the agency stating, "We worry about how the rule could affect Medicare beneficiaries where such lab services are necessary for a physician to make critical decisions that affect patients' health and well-being, often under significant time constraints, and urge CMS to consider these situations as they examine this policy." The letter was signed by 87 other lawmakers. A group of 34 senators sent a similar letter to CMS on Feb. 11.

But the AMA, along with several other members of organized medicine, called for the agency to abolish the signature rule permanently.

"We clearly communicated to CMS that the added administrative hassles this rule would impose on physicians were burdensome and unnecessary," said AMA President Cecil B. Wilson, MD. "CMS' decision to reverse this policy will allow physicians to spend less time on paperwork and more time on patient care. This decision is an important step as the administration works to ease regulatory burdens for businesses, including physician practices."

CMS spokeswoman Ellen Griffith would not comment on how the agency would go about rescinding the rule. "All I can confirm is that the agency is taking another look at the policy and considering next steps," she said.

Not a new concept

The lab signature policy had been in development for several years. CMS proposed the rule in 2009, but it chose not to finalize it because of concerns raised during a public comment period. In 2010, agency officials had enough confidence that they had ironed out those details that they decided to include a signature requirement in the 2011 fee schedule.

The rule would not create an extra burden for physicians, CMS had said, because in most instances a physician already is annotating the patient's medical record with either a signature or an order, as well as with any paperwork needed to identify the lab test. The agency also noted that a signature in ink would not be required for similar requisitions made over the phone or through an electronic medical record system.

In the final fee schedule rule, CMS further defended its decision by stating that the policy would make it easier for lab technicians to know whether a test was appropriately requested. Also, "potential compliance problems would be minimized for laboratories during the course of a subsequent Medicare audit because a signature would be consistently required."

But physicians argued that the signature requirement would create an additional barrier between them and their patients. The policy could interfere with a physician's ability to practice medicine professionally and efficiently, said Jeff Terry, MD, a urologist in Mobile, Ala. He said physicians can't be in front of patients to sign requisitions all of the time.

For instance, Dr. Terry said, a scenario might exist where a physician performing surgery in the operating room receives an urgent call for another patient. The doctor already is aware of the second patient's problem, so he wants the patient to get an x-ray immediately, then follow up with the physician in the office later. The physician's nurse could provide the patient with the requisition needed to obtain the x-ray, expediting the process in a way that benefits both patient and physician, he said. This handoff would not be possible if a physician signature requirement were in place.

"Patients with kidney stones don't want to wait another day for me to sign the paper before they can do a test," he said.

Before the most recent rule change, CMS had been very clear that doctor sign-offs weren't required, said JoAnne Glisson, senior vice president of the American Clinical Laboratory Assn. in Washington, D.C. Consequently, almost all requisitions arrive at labs without signatures.

The new policy had left labs facing a choice between two unpleasant options if they wanted to be paid by Medicare for all the services they provide, said Richard Daly, CEO of Laboratory Partners, a large full-service lab company based in Cincinnati that runs about 5.5 million tests a year. "One would be to not provide the test -- or provide the test and chase the physician or facility for a signature," he said. "Neither was a great solution."

Glisson said senior CMS officials informed the lab association that they were going to rescind the policy. She said the agency would need to issue an interim final rule to undo the requirement before April 1, but the new document had not been released at this article's deadline.

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