Several e-Network members have questioning the need for a physician's order to 'keep ahead' a reasonable number of crossmatched units for patients who 1) have an alloantibody that makes finding compatible blood difficult, 2) are actively bleeding, or 3) have an expected ongoing need for blood transfusion. With regard to the patients with alloantibodies, the original physician's order may have only been for a type and screen, and the physician may not even know the his/her patient has an unexpected, difficult to crossmatch antibody. With regard to bleeding patients, there may be a physician's order to crossmatch a certain number of units but, because of an ongoing patient's ongoing bleeding, the blood bank desires to keep ahead of patient's needs, rather than get caught short. Sometimes there are verbal communications from the OR about anticipated need for additional units, but often these communications are not accompanied by a written order to stay ahead. The inquiring member sees the above situation as problematic, in that there may be billing for crossmatches that were never specifically ordered by a physician. This member wants to do what is best for the patient, but is concerned over compliance issues, and is worried about billing for work that is not actually ordered.

The following were submitted in response to the above situation:

1. A member stated that her facility's policy was to notify a physician whenever a type and screen detected an unexpected antibody, and to encourage that physician to order crossmatched blood. According to the member, this approach eliminates one of the problems with billing, since if a physician's order could not be obtained, any work done would be at the expense of the lab. It is the policy of this member's institution to prohibit billing for any test that is not ordered by a physician.

2. A second member commented that he would prefer to face incarceration for the sake of patient safety, than to worry about a patient being harmed by delaying treatment to obtain a physician order to perform a test. This member went on to say that he hoped the approach used at his facility would prevent such an outcome. At this member's facility additional units are prepared [without specific physician orders] for patients who have alloantibodies, provided the patient has had a crossmatch order. For those patients who only have type and screen requests, the orders are automatically converted to crossmatch orders! Their approach to avoid the fraud and abuse issue is to make this automatic change in the physician order a component of the approved reflex testing that has been reviewed and blessed by the institutional Medical Executive Committee.

Editor's Note: It seems to me that this approach protects the blood bank director, but may or may not protect the hospital CEO and/or hospital medical director. It might be prudent to not bill for work that has not been specifically ordered, since the Medicare police can be very strict.

3. A third member stated that she was aware of instances where the insurance company refused to reimburse a hospital for the "stay ahead" units, as there was no written order.

4. A fourth member said that in his personal opinion (with no legal authority) that he viewed this situation as a patient safety issue, and that the risk of not having blood available in an emergency far outweighed the cost. This member felt that the legal and responsible
authority for the additional crossmatches should be the blood bank physician acting in the patient's behalf. The member also thought that the patient should view this as an insurance policy with a very low premium considering the potential benefit, especially since most of the cost is picked up by a third party.

Editor's Note: It is not clear that most of the cost would be picked up by a third party, based on reply #3 above.

5. A fifth member reported that whenever a type and screen is positive for an unexpected antibody, or whenever a patient has a history of an unexpected antibody, the patient's physician is notified and informed of the antibody and any potential delay in providing compatible units. This member's blood bank will not perform a crossmatch for a non-bleeding patient unless a physician has ordered the test. With regards to actively bleeding patients, this institution has a computer system that allows them to perform a crossmatch and to tag the unit without billing the patient, whenever the test has been performed without a physician's order. This is important because the blood bank routinely sets up extra units on actively bleeding patients (to stay ahead), yet does not bill for work unless the units are specifically ordered by a physician.

6. A sixth member reported that her institution treated a patient who was a chronic transfusion recipient (the patient had lymphoma) and who had multiple red cell antibodies. The rate of compatible units for this patient was about 1 in 100. In order to find enough compatible units for this patient, the blood bank antigen-typed numerous units in an ongoing anticipation of transfusion, so that the patient would not have to wait when blood was actually ordered. At some point the patient was discharged and expired at home. The husband called later and was furious that the laboratory had typed so many units of blood (and that the lab had the nerve to bill for the work that they did) and refused to pay. The hospital allegedly lost close to $6,000.

7. Finally, a member had some thoughtful suggestions based on the approach used at her small community hospital:

• When an alloantibody is identified, a canned text comment pops up on the computer screen that instructs a technologist how to proceed, such as when to notify a pathologist, etc. One instruction is as follows:
  
  - Notify physician of antibody and inquire if any additional crossmatches are required.
  - Check action taken: Dr. [ ] notified: [ ] additional crossmatches required.

  This appears on the medical chart report as documentation of a physician order. (Most of the other instructions are suppressed and do not appear on the chart report).

• Operating Room RN's are supposed to chart stay ahead orders. In reality, the lab is often responsible for entering additional product orders in the LIS. When this is done, it is noted as a verbal order, i.e. "V.O. Dr. [ ]". This verbal order documentation is a part of the laboratory computer record. Thus far CAP and CLIA inspectors have accepted this approach.

Editor's Final Note: I believe that no patient should be denied a timely transfusion, even if a crossmatch has not be specifically ordered by a patient's physician. However, if a test has not been ordered by a physician (or other authorized individual), it is risky to bill for it.

Please submit comments to the e-Network Forum.

Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator