Effective Tuesday, June 26, 2012, during visit orders for selected mailout tests will require pathologist approval.  Mailout tests included are primarily genetic tests with slow turnaround time and/or very high charges. 

• Page 5379 for pathologist covering mailout approval. 
• If approval is granted, then select the pathologist who approved the test from the drop down menu.
• Mailouts staff will not process order without pathologist approval.

When the restricted tests are ordered on inpatient encounters, a prompt will show as follows:

Background: 
An analysis of mailout test ordering patterns revealed a number of issues with inpatient mailout test ordering including:

• Challenges with genetic counseling while patients are acutely ill
• Challenges with follow-up of results that come back weeks to months after discharge
• Lack of reimbursement for testing ordered during inpatient encounters 

Reimbursement:  On inpatient encounters, most reimbursement is by diagnosis related group (DRG) without specific coverage of diagnostic testing.  Patients may incur significant financial liability from charges associated with inpatient encounters, especially if insurance coverage involves high deductible or co-insurance coverage models.

Factors:

• Will mailout test results be needed for management of patients during the inpatient stay?
• Will mailout results be reasonably expected to be available while the patient is an inpatient?

There are circumstances where slow turnaround time tests are needed for inpatient management.  Example: infant in the Neonatal ICU with a suspected inborn error of metabolism who is expected to be in the hospital for months. However, analysis of ordering patterns has shown that currently many genetic tests are being ordered on short inpatient encounters, often when outpatient follow up was set up within a short span of time. 

Counseling: 

• Outpatient ordering of tests allows for genetic counseling to determine that patients (or parents/guardians) are comfortable with the testing being ordered and its implications for their relatives.

Direct Billing:

• A number of the high-priced tests can be ordered in the outpatient setting by direct billing, whereby the insurance company is billed directly for the testing. 
• This option, if available, limits both patient and hospital financial liability.

Questions should be directed to Matthew Krasowski, MD, PhD, medical director of the Clinical Chemistry Laboratory (384-9380, matthew-krasowski@uiowa.edu).