Management Q and A

Edited by Christopher S. Frings PhD, CSP

Addressing issues on

standing orders and Medicare, and procrastination revisited

Our hospital operates a small
extended-care facility with the same physicians covering clinic, hospital, hospice and extended-care patients. The extended-care facility sends urine samples to the hospital lab with instructions to culture, if indicated. We have written criteria for making this judgment. In Medicares view, are we doing urine cultures without a physicians order? Is a standing order covering all the patients sufficient to cover Medicare regulations for this?

Alton Sturtevant recommends,
You should consult your compliance officer, local Medicare medical director and attorney to make your final determination of this policy. Your question really relates to performing reflex testing on routine urinalysis to a urine culture, based on preset criteria set by the physician. Your compliance manual should address reflex testing for your facility. 

In general terms, for a reflex test to be acceptable to Medicare, some criteria must be met; and the physician must agree, in writing, with those used to perform the reflex. I would have the physician redo the reflex agreement at least annually. The physician must also be able to order the urinalysis without the reflex at any time. A reflex form for this purpose would simplify the protocol or any other reflex procedures that you may be asked to perform. I would provide information on the form to indicate how you will bill each of the procedures to Medicare and include the Medicare fee to ensure full disclosure. Remember to consider all medical-necessity issues that relate to any reflex protocol and the need for Advanced Beneficiary Notifications, as they may pertain. On a more practical note, it would be helpful to the laboratory and ordering physician to provide two different ordering codes for this purpose. One of the codes would be for the urinalysis alone and the other for the urinalysis that will automatically reflex to culture.

According to Larry Crolla, Usually, reflex testing should be cleared with the medical staff ahead of time. For example, all physicians need to be notified that when they order a certain test code, they will get reflex testing. They must also be able to order the test without reflex testing. So, this is not a standing order question, but one of reflex testing. Again, as long as the physicians know that by ordering a certain code, they get the reflex, if needed and they also have the ability (usually using another test code) to order the same test without reflex testing you should be covered. With this and any type of billing/compliance question, you should check with your hospital/institution compliance/billing personnel.

Marti Bailey points out, In the Office of Inspector Generals compliance program guidance for clinical laboratories, the following advice is given: Reflex testing occurs when initial test results are positive or outside normal parameters and indicate that a second related test is medically appropriate. To avoid performing unnecessary reflex tests, labs may want to design their requisition form in such a way that would only allow for the reflex test when necessary. Therefore, the condition under which the reflex test will be performed should be clearly indicated on the requisition form. your test requisition must list both urinalysis and urine culture, as well as a listing for urinalysis reflexed to urine culture, with the criteria that trigger the reflexive testing spelled out right on the requisition. In this way, users have the option of ordering the test without a reflexive component if they want to. Or, if they do choose the reflex option, they clearly understand the conditions that will trigger the automatic reflex. Having your requisition designed this way will, in my opinion, document the physicians order for a reflexive urine culture when the test is ordered.

Ms. Bailey adds, The biggest issue that I see with your current practice is that reflex tests must be medically appropriate, which is just another way of saying that tests must be medically necessary. With common tests especially, it is extremely difficult to justify medical necessity for each and every patient to which the reflex policy will apply. Look at the criteria that you are using as the basis for reflexing to a urine culture, and ask yourself if every single patient who meets those criteria will need a urine culture in order to provide additional diagnostic information that is required for appropriate patient care. This is a really big order to fill. And that is what is so difficult about implementing standing-order policies, whether they are for reflexive testing or for other services. Unless a particular reflexive strategy is either a widely accepted standard of care or is required for confirmation, medical necessity requires you to evaluate the needs of each individual patient because payers only want to pay for services that are medically necessary for that particular patient.

Bottom line. The panel offers good and practical advice. Take this issue to your laboratory compliance officer and possibly your corporate compliance officer. Any laboratory reflex policies that you have need to be approved by your medical executive committee with guidance from your compliance

More on procrastination

Is it possible that a person
might procrastinate because he is afraid of success, rather than failure? Is it possible that procrastination occurs because when a person has done the right things at the right times and for the right reasons he might not have received the recognition that was anticipated and/or deserved, or that possibly the person was put down for the accomplishment?

I would answer, Yes, it is
possible, to all of your questions. When a person feels the way you describe, this is what Zig Ziglar calls stinking thinking, which leads to hardening of the attitudes! The person you describe needs to re-evaluate his situation. Sounds like he is working for an unappreciative manager. Having goals and staying focused are important for all of us. He should sit down with his manager and set up goals and rewards for himself for the coming 12 months. If the manager does not agree to do this, your friend should stay employed there only until he can find something better. Sounds like this person is procrastinating partly because he feels no one cares.

According to Alton Sturtevant, I assume that almost anything is possible and that procrastination is a result of fear of success due to prior negative reactions. The recipient of such feelings from his management could gauge the response by reviewing the assignment with his boss to determine if his perceived feeling has any basis in fact. They could discuss the challenge and their approach and solution. Ask for a critique from the boss on the approach and result. If your boss is happy with your results, then you should not be disheartened into procrastination by comments made by co-workers.

Larry Crolla points out, Your question is really about what motivates people. There are a million books on that subject, as well as a million ideas. To address your specific issue yes, some people may be afraid of success. In some flower-growing countries, because poppies are shipped in boxes, the tall ones are cut down to fit, and all the poppies are then even. This is known as the tall poppy complex, meaning that people will not succeed above the rest because they do not want to stand out and be picked on or looked down upon in that culture. It is hard to know what motivates the person in your question, since we have not been exposed to his personality.

Marti Bailey advises, Although anything is possible, I would have to say that I disagree with your assessment. Rather than fear of success, I would characterize your description as just another face of passive resistance. The explanation that lack of recognition in the past is at the root of this procrastination does not hold much water with me. I believe that each individual is his own best critic and supporter, and that recognition is not entitlement. If this procrastination has been occurring on your time, I would put an end to it. If you assign a task to an employee who has the proper skills, and provide him with the time and tools to do it, then you need to hold him accountable. To try to probe his deepest psyche to find out why he is not completing the task should not be necessary.

Ms. Bailey adds, Recognition is an important motivational tool, but in many cases I have seen, recognition is expected and/or awarded for simply doing your job. If an employee is given a special project to work on during work hours and does a great job, should he be recognized? Of course, he should be thanked for the great job and given feedback about how much the effort put into the project and the quality of this work is appreciated. And the results of his assignment should be taken into consideration for his performance appraisal. But is greater recognition than this due? I do not think so. When we start dishing out special recognition for things that people are expected to do, praise becomes inflated and its value diminished accordingly. Should an employee receive special recognition for being really nice to everybody? I expect employees to do this all the time, so the answer is no. This is a performance expectation, so it does not deserve special recognition. Should it be noted on the employees performance appraisal that he has excellent interpersonal skills? Yes, this is the proper place to recognize this behavior.

Bottom line. The panel is not convinced! You may be exhibiting passive resistance. You need to have a discussion with your manager and express your feelings. Recognition is not an entitlement; it must be earned. Some managers are better at offering recognition than others. You are responsible for your own destiny. l

Christopher S. Frings is an internationally known consultant and speaker on the topics of leadership, managing change, time management, reaching goals, and stress management. His consulting firm, Chris Frings & Associates, is in Birmingham, AL.

Movember 2003: Vol. 35, No. 11

© 2003 Nelson Publishing, Inc. All rights reserved.