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COMPLYING WITH DOCUMENTATION REQUIREMENTS
FOR LABORATORY SERVICES

 CMS published a document with helpful tips on documentation for laboratory services. It says that majority of improper payments for laboratory services identified by the Comprehensive Error Rate Testing (CERT) Program were due to insufficient documentation. 

What does it mean? 

Insufficient documentation means something was missing from the medical records. 

For example, the medical record was missing: 

  • Documentation to support intent to order, such as a signed progress note, signed office visit note, or signed physician order 
  • Documentation to support the medical necessity of ordered services
Doctor to doctor

  

What to do? 

  • The physician who treats a beneficiary must order all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests for a specific medical problem. The physician uses the results to manage the beneficiary’s specific medical problem and may furnish a consultation. Tests not ordered by the physician are not considered reasonable and necessary. 
  • The physician should clearly indicate all tests to be performed (for example, “run labs” or “check blood” by itself does not support intent to order) when completing progress notes. 
  • Documentation in the patient’s medical record must support the medical necessity for ordering the service(s) per Medicare regulations and applicable Local Coverage Determinations (LCDs). Submit these medical records if they are requested. 
  • Keep these records available to submit upon request: 
  • Progress notes or office notes
    • Physician order or intent to order
    • Laboratory results
    • Attestation or signature log for illegible signature(s) 

 

Signature Requirements 

  • Unsigned physician orders or unsigned requisitions alone do not support physician intent to order. 
  • Physicians should sign all orders for diagnostic services to avoid potential denials. 
  • If the signature is missing on a progress note, which supports intent, the ordering physician must complete an attestation statement and submit it with the response. For an example of a signature attestation statement, visit the CERT Provider website. If the signature is illegible, an attestation statement or signature log is acceptable. 
  • Attestation statements are unacceptable for unsigned physician orders or requisitions.  

! While a physician order is not required to be signed, the physician must clearly document in the medical record his or her intent that the test be performed.  

Read the Full document

Useful links: 

Provider Compliance

Clarification of ordering and certifying.

Doctor to doctor

Issues schedule

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Insights
September 2018