Physician Signature Requirements for Diagnostic Tests

A physician’s signature is not required on orders for clinical diagnostic tests (including X-ray, laboratory and other diagnostic tests) that are paid on the basis of the clinical laboratory fee schedule or the Medicare Physician Fee Schedule, or for physician pathology services. While a physician order is not required to be signed, the physician must clearly document in the medical record his intent that the test be performed.

* Signature Guidelines for Medical Review Purposes – CMS CR 6698: http://www.cms.gov/Transmittals/downloads/R327PI.pdf

* “Documentation Signature Requirements” job aid: http://www.trailblazerhealth.com/Publications/Job Aid/DocumentationSignatureRequirements.pdf

* Documentation Tips for Outpatient Lab and Diagnostic Tests: http://www.trailblazerhealth.com/CERT/DocumentationTips