The Centers for Medicare & Medicaid Services (CMS) reported that the majority of improper payments for laboratory services identified by the Comprehensive Error Rate Testing (CERT) Program were attributable to insufficient documentation.

Insufficient documentation means that something was missing from the medical records (e.g., signed physician order, documentation to support intent to order, documentation to support the medical necessity of ordered services).

To help avoid these errors, CMS provides the following 10 tips.

Laboratory Document Requirements

1. The physician who is treating the beneficiary must order all diagnostic X-ray tests, diagnostic laboratory tests and other diagnostic tests. The physician who is treating the beneficiary is the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary.

2. When completing progress notes, the physician should clearly indicate all tests to be performed (e.g., “run labs” or “check blood” by itself does not support intent).

3. 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 in response to a request for medical records.

4. Keep these records available upon request:

  • Progress notes or office notes;
  • Physician order/intent to order;
  • Laboratory results; and/or
  • Attestation/signature log for illegible signature(s).

Laboratory Signature Requirements

5. Unsigned physician orders or unsigned requisitions alone do not support physician intent.

6. Physicians should sign all orders for diagnostic services to avoid potential denials.

7. 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.

8. Attestation statements are not acceptable for unsigned physician orders/requisitions.

Laboratory Ordering/Referring Services

9. If you bill laboratory services to Medicare, you must obtain the treating physician’s signed order (or progress note to support intent to order) and documentation to support medical necessity for the ordered service(s). These records may be housed at another location (for example, a nursing facility, hospital, or referring physician office). Note: 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.

10. Providers who order diagnostic services for Medicare patients must also maintain documentation of the order/intent to order and medical necessity of the service(s) in the patient’s medical record. Keep this information available and submit it, along with the test results, upon request for a Medicare claim review.

Bonus tip: Cooperation among ordering/referring providers and facilities that perform diagnostic tests is crucial to reducing errors and avoiding claim denials. The use of laboratory billing software may help, as can outsourcing to a laboratory billing expert like PGM.