This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.
Debunking the myth
Standing or protocol orders for common tests and procedures (e.g., strep test, urinalysis, EKG, pulse oximetry, orthostatic vitals, etc.) are not prohibited by the Centers for Medicare and Medicaid (CMS) or Joint Commission. Hospitals may use them if they are approved and regularly reviewed by medical, nursing, and pharmacy leadership; align with evidence-based guidelines; include clear initiation criteria; and promptly authenticated by the ordering practitioner or, when permitted, another responsible practitioner in accordance with state scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations.1-3 Protocol orders are also commonly used in ambulatory practice settings for similar tests and procedures and similar guardrails should be in place as well.
Caveats concerning the implementation of such orders exist, including state law and conflicting federal law, which can impose additional limits.1,4 Additionally, payers, including Medicare, may deny payment1 if the patient has not been evaluated by a physician or if services are not documented as medically necessary for an individual patient.
Background
Much of the formal language about standing orders comes from CMS’s hospital Conditions of Participation (CoPs). CMS’s outpatient ordering guidance for hospital outpatient services is silent about standing orders or protocols, but it does not prohibit them. Instead, CMS explains what it does require (e.g., compliance with CoP requirements, services ordered by a licensed practitioner responsible for the patient and acting within scope, medical staff approval, and regular review by nursing and pharmacy leadership).1,2
Key takeaway
Hospitals and practices may use evidence-based standing orders approved by clinical leadership to initiate care. For Medicare payment, however, each service must still be tied to an authorized treating clinician and documented as medically necessary for the individual patient. Clinical leadership should regularly review and update protocols and standing orders to ensure they remain evidence-based and compliant with scope-of-practice, billing, and other requirements.
AMA policy
- Fifteen Month Lab Standing Orders D-260.991
- Increasing Availability of Naloxone and Other Safe and Effective Overdose Reversal Medications H-95.932
- Cardiac Resuscitation by Nurses H-360.998
Resources
- 2013 CMS State Operations Manual (PDF): Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Accessed January 2026.
- 2015 CMS State Operations Manual (PDF): Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Accessed January 2026.
- September 2025 Joint Commission Requirements for Hospital Programs (PDF). Accessed January 22, 2026.
- 2025 AMA STEPS Forward® Saving Time Playbook. Accessed February 2025.
- Download this myth: Are standing orders for routine care prohibited? (PDF)
References
- Centers for Medicare & Medicaid Services (CMS). State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Pub. 100-07, Transmittal 95. 2013. Accessed January 22, 2026. https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r95soma.pdf
- Centers for Medicare & Medicaid Services (CMS). State Operations Manual Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Pub. 100-07, Transmittal 137. 2015:13-16. https://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r137soma.pdf
- Joint Commission. Joint Commission Requirements for Hospital Programs. Published online September 30, 2025:RC.12.01.01 EP 5 (formerly MM.04.01.01, EP 15). Accessed January 22, 2026. https://digitalassets.jointcommission.org/api/public/content/6af7e77646254ef89894bdb37ad730c7?v=e89f4141
- Centers for Medicare & Medicaid Services. 42 CFR 482.13 -- Condition of Participation: Patient’s Rights. 482.13. 2024. Accessed January 23, 2026. https://www.ecfr.gov/current/title-42/part-482/section-482.13
Debunking Regulatory Myths overview
Visit the overview page for information on additional myths.
Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues. Additionally, all applicable laws and accreditation standards should be considered when applying information to your own practice.
