Labs Decision Tree
This set of questions will assist with review of Documentation requirements:
1. Did the provider order the laboratory test for a specific medical problem?
2. Was the laboratory test ordered by the provider who is managing the patient's specific medical problem?
Yes No
3. Is there a signed order or requisition listing the specific test?
Yes No
4. If the order or requisition is unsigned, is there an authenticated medical record supporting the physician's intent to order the test?
Yes No
5. If the signature is missing on the progress note which supports the intent, did the physician complete an attestation statement and submit it with the records?
Yes No
6. Does the medical record contain the laboratory test results showing the procedure was performed?
Yes No
7. INDIVIDUALIZED LABORATORY TESTS AND COVERAGES:
Vitamin D Assay 82306 Definitive Drug Testing (G0480-G0483)
Vitamin D Assay 82306
8. Does the order or requisition list the specific test?
Yes No
9. Does the medical record show a covered indication/diagnosis?
Yes No
10. Does the medical record contain relevant medical history, pertinent tests, procedures and is related to the complaint of the patient for that visit?
Yes No
11. Does the medical record show adequate replacement has been accomplished? And if so, have 12 months elapsed since last tested?
Yes No
Definitive Drug Testing (G0480-G0483)
8. Does the test identify a specific substance or metabolite that is inadequately detected by a presumptive UDT?
Yes No
9. Does the test match the stage of screening, treatment, or recovery and the documented history of the individual beneficiary?
Yes No
10. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings
- Stage of treatment or recovery;
- Suspected abused substance;
- Substances that may present high risk for additive or synergistic interactions with prescribed medication (e.g., benzodiazepines, alcohol).
Yes No
11. Does the medical record include an appropriate testing frequency based on the stage of screening, treatment, or recovery. Is the rationale for the drugs/drug classes ordered documented and are the results in the medical record and used to direct care? (GROUP B)
Yes No
12. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings;
- Current treatment plan;
- Prescribed medication(s)
- Risk assessment
Yes No
13. If the frequency of testing is beyond the appropriate testing frequency, does the record document individual patient needs to substantiate the need for additional testing?
- Patient response to prescribed medication suddenly changes
- Patient side effect profile changes
- To assess for possible drug-drug interactions
- Sudden change in patient’s medical condition
- Patient admits to use of illicit or non-prescribed controlled substance.
Yes No
14. If testing is direct to definitive UDT, without a presumptive test, or done with negative presumptive, does the record contain an individualized treatment plan detailing the rationale and/or to detect a drug known not to be detected by presumptive testing?
Yes No
15. Was drug testing done on two different specimen types from the same patient on the same date of service for the same drug/metabolite/analytes?
Yes No
16. Was the drug test obtained for the purpose of specimen validity including, but not limited to pH, specific gravity, oxidants, creatine?
Yes No
17. Was the UDT for medico-legal and/or employment purposes or to protect a physician from drug diversion charges?
Yes No
9. Does the test identify drugs in a large class of drugs?
Yes No
10. Does the test match the stage of screening, treatment, or recovery and the documented history of the individual beneficiary?
Yes No
11. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings
- Stage of treatment or recovery;
- Suspected abused substance;
- Substances that may present high risk for additive or synergistic interactions with prescribed medication (e.g., benzodiazepines, alcohol).
Yes No
12. Does the medical record include an appropriate testing frequency based on the stage of screening, treatment, or recovery. Is the rationale for the drugs/drug classes ordered documented and are the results in the medical record and used to direct care? (GROUP B)
Yes No
13. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings;
- Current treatment plan;
- Prescribed medication(s)
- Risk assessment
Yes No
14. If the frequency of testing is beyond the appropriate testing frequency, does the record document individual patient needs to substantiate the need for additional testing?
- Patient response to prescribed medication suddenly changes
- Patient side effect profile changes
- To assess for possible drug-drug interactions
- Sudden change in patient’s medical condition
- Patient admits to use of illicit or non-prescribed controlled substance.
Yes No
15. If testing is direct to definitive UDT, without a presumptive test, or done with negative presumptive, does the record contain an individualized treatment plan detailing the rationale and/or to detect a drug known not to be detected by presumptive testing?
Yes No
16. Was drug testing done on two different specimen types from the same patient on the same date of service for the same drug/metabolite/analytes?
Yes No
17. Was the drug test obtained for the purpose of specimen validity including, but not limited to pH, specific gravity, oxidants, creatine?
Yes No
18. Was the UDT for medico-legal and/or employment purposes or to protect a physician from drug diversion charges?
Yes No
10. Does the test identify a specific substance or metabolite that is not detected by presumptive UDT such as fentanyl, meperidine, synthetic cannabinoids, ketamine and other synthetic/analog drugs?
Yes No
11. Does the test match the stage of screening, treatment, or recovery and the documented history of the individual beneficiary?
Yes No
12. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings
- Stage of treatment or recovery;
- Suspected abused substance;
- Substances that may present high risk for additive or synergistic interactions with prescribed medication (e.g., benzodiazepines, alcohol).
Yes No
13. Does the medical record include an appropriate testing frequency based on the stage of screening, treatment, or recovery. Is the rationale for the drugs/drug classes ordered documented and are the results in the medical record and used to direct care? (GROUP B)
Yes No
14. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings;
- Current treatment plan;
- Prescribed medication(s)
- Risk assessment
Yes No
15. If the frequency of testing is beyond the appropriate testing frequency, does the record document individual patient needs to substantiate the need for additional testing?
- Patient response to prescribed medication suddenly changes
- Patient side effect profile changes
- To assess for possible drug-drug interactions
- Sudden change in patient’s medical condition
- Patient admits to use of illicit or non-prescribed controlled substance.
Yes No
16. If testing is direct to definitive UDT, without a presumptive test, or done with negative presumptive, does the record contain an individualized treatment plan detailing the rationale and/or to detect a drug known not to be detected by presumptive testing?
Yes No
17. Was drug testing done on two different specimen types from the same patient on the same date of service for the same drug/metabolite/analytes?
Yes No
18. Was the drug test obtained for the purpose of specimen validity including, but not limited to pH, specific gravity, oxidants, creatine?
Yes No
19. Was the UDT for medico-legal and/or employment purposes or to protect a physician from drug diversion charges?
Yes No
11. Does the test identify drugs when a definitive concentration of a drug is needed to guide management (e.g., discontinuation of THC use according to a treatment plan)?
Yes No
12. Does the test match the stage of screening, treatment, or recovery and the documented history of the individual beneficiary?
Yes No
13. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings
- Stage of treatment or recovery;
- Suspected abused substance;
- Substances that may present high risk for additive or synergistic interactions with prescribed medication (e.g., benzodiazepines, alcohol).
Yes No
14. Does the medical record include an appropriate testing frequency based on the stage of screening, treatment, or recovery. Is the rationale for the drugs/drug classes ordered documented and are the results in the medical record and used to direct care? (GROUP B)
Yes No
15. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings;
- Current treatment plan;
- Prescribed medication(s)
- Risk assessment
Yes No
16. If the frequency of testing is beyond the appropriate testing frequency, does the record document individual patient needs to substantiate the need for additional testing?
- Patient response to prescribed medication suddenly changes
- Patient side effect profile changes
- To assess for possible drug-drug interactions
- Sudden change in patient’s medical condition
- Patient admits to use of illicit or non-prescribed controlled substance.
Yes No
17. If testing is direct to definitive UDT, without a presumptive test, or done with negative presumptive, does the record contain an individualized treatment plan detailing the rationale and/or to detect a drug known not to be detected by presumptive testing?
Yes No
18. Was drug testing done on two different specimen types from the same patient on the same date of service for the same drug/metabolite/analytes?
Yes No
19. Was the drug test obtained for the purpose of specimen validity including, but not limited to pH, specific gravity, oxidants, creatine?
Yes No
20. Was the UDT for medico-legal and/or employment purposes or to protect a physician from drug diversion charges?
Yes No
12. Does the definitive test identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patient’s self-report, presentation, medical history, or current prescribed pain medication plan?
Yes No
13. Does the test match the stage of screening, treatment, or recovery and the documented history of the individual beneficiary?
Yes No
14. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings
- Stage of treatment or recovery;
- Suspected abused substance;
- Substances that may present high risk for additive or synergistic interactions with prescribed medication (e.g., benzodiazepines, alcohol).
Yes No
15. Does the medical record include an appropriate testing frequency based on the stage of screening, treatment, or recovery. Is the rationale for the drugs/drug classes ordered documented and are the results in the medical record and used to direct care? (GROUP B)
Yes No
16. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings;
- Current treatment plan;
- Prescribed medication(s)
- Risk assessment
Yes No
17. If the frequency of testing is beyond the appropriate testing frequency, does the record document individual patient needs to substantiate the need for additional testing?
- Patient response to prescribed medication suddenly changes
- Patient side effect profile changes
- To assess for possible drug-drug interactions
- Sudden change in patient’s medical condition
- Patient admits to use of illicit or non-prescribed controlled substance.
Yes No
18. If testing is direct to definitive UDT, without a presumptive test, or done with negative presumptive, does the record contain an individualized treatment plan detailing the rationale and/or to detect a drug known not to be detected by presumptive testing?
Yes No
19. Was drug testing done on two different specimen types from the same patient on the same date of service for the same drug/metabolite/analytes?
Yes No
20. Was the drug test obtained for the purpose of specimen validity including, but not limited to pH, specific gravity, oxidants, creatine?
Yes No
21. Was the UDT for medico-legal and/or employment purposes or to protect a physician from drug diversion charges?
Yes No
13. Does the definitive test identify a negative, or confirm a positive, presumptive UDT result that is inconsistent with a patient’s self-report, presentation, medical history, or current prescribed pain medication plan?
Yes No
14. Does the test match the stage of screening, treatment, or recovery and the documented history of the individual beneficiary?
Yes No
15. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings
- Stage of treatment or recovery;
- Suspected abused substance;
- Substances that may present high risk for additive or synergistic interactions with prescribed medication (e.g., benzodiazepines, alcohol).
Yes No
16. Does the medical record include an appropriate testing frequency based on the stage of screening, treatment, or recovery. Is the rationale for the drugs/drug classes ordered documented and are the results in the medical record and used to direct care? (GROUP B)
Yes No
17. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings;
- Current treatment plan;
- Prescribed medication(s)
- Risk assessment
Yes No
18. If the frequency of testing is beyond the appropriate testing frequency, does the record document individual patient needs to substantiate the need for additional testing?
- Patient response to prescribed medication suddenly changes
- Patient side effect profile changes
- To assess for possible drug-drug interactions
- Sudden change in patient’s medical condition
- Patient admits to use of illicit or non-prescribed controlled substance.
Yes No
19. If testing is direct to definitive UDT, without a presumptive test, or done with negative presumptive, does the record contain an individualized treatment plan detailing the rationale and/or to detect a drug known not to be detected by presumptive testing?
Yes No
20. Was drug testing done on two different specimen types from the same patient on the same date of service for the same drug/metabolite/analytes?
Yes No
21. Was the drug test obtained for the purpose of specimen validity including, but not limited to pH, specific gravity, oxidants, creatine?
Yes No
22. Was the UDT for medico-legal and/or employment purposes or to protect a physician from drug diversion charges?
Yes No
14. Does the test rule out an error as the cause of a presumptive UDT result?
Yes No
15. Does the test match the stage of screening, treatment, or recovery and the documented history of the individual beneficiary?
Yes No
16. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings
- Stage of treatment or recovery;
- Suspected abused substance;
- Substances that may present high risk for additive or synergistic interactions with prescribed medication (e.g., benzodiazepines, alcohol).
Yes No
17. Does the medical record include an appropriate testing frequency based on the stage of screening, treatment, or recovery. Is the rationale for the drugs/drug classes ordered documented and are the results in the medical record and used to direct care? (GROUP B)
Yes No
18. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings;
- Current treatment plan;
- Prescribed medication(s)
- Risk assessment
Yes No
19. If the frequency of testing is beyond the appropriate testing frequency, does the record document individual patient needs to substantiate the need for additional testing?
- Patient response to prescribed medication suddenly changes
- Patient side effect profile changes
- To assess for possible drug-drug interactions
- Sudden change in patient’s medical condition
- Patient admits to use of illicit or non-prescribed controlled substance.
Yes No
20. If testing is direct to definitive UDT, without a presumptive test, or done with negative presumptive, does the record contain an individualized treatment plan detailing the rationale and/or to detect a drug known not to be detected by presumptive testing?
Yes No
21. Was drug testing done on two different specimen types from the same patient on the same date of service for the same drug/metabolite/analytes?
Yes No
22. Was the drug test obtained for the purpose of specimen validity including, but not limited to pH, specific gravity, oxidants, creatine?
Yes No
23. Was the UDT for medico-legal and/or employment purposes or to protect a physician from drug diversion charges?
Yes No
15. Does the test identify non-prescribed medication or illicit use for ongoing safe prescribing of controlled substances?
Yes No
16. Does the test match the stage of screening, treatment, or recovery and the documented history of the individual beneficiary?
Yes No
17. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings
- Stage of treatment or recovery;
- Suspected abused substance;
- Substances that may present high risk for additive or synergistic interactions with prescribed medication (e.g., benzodiazepines, alcohol).
Yes No
18. Does the medical record include an appropriate testing frequency based on the stage of screening, treatment, or recovery. Is the rationale for the drugs/drug classes ordered documented and are the results in the medical record and used to direct care? (GROUP B)
Yes No
19. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings;
- Current treatment plan;
- Prescribed medication(s)
- Risk assessment
Yes No
20. If the frequency of testing is beyond the appropriate testing frequency, does the record document individual patient needs to substantiate the need for additional testing?
- Patient response to prescribed medication suddenly changes
- Patient side effect profile changes
- To assess for possible drug-drug interactions
- Sudden change in patient’s medical condition
- Patient admits to use of illicit or non-prescribed controlled substance.
Yes No
21. If testing is direct to definitive UDT, without a presumptive test, or done with negative presumptive, does the record contain an individualized treatment plan detailing the rationale and/or to detect a drug known not to be detected by presumptive testing?
Yes No
22. Was drug testing done on two different specimen types from the same patient on the same date of service for the same drug/metabolite/analytes?
Yes No
23. Was the drug test obtained for the purpose of specimen validity including, but not limited to pH, specific gravity, oxidants, creatine?
Yes No
24. Was the UDT for medico-legal and/or employment purposes or to protect a physician from drug diversion charges?
Yes No
16. Was the test used in a differential assessment of medication efficacy, side effects, or drug-drug interactions?
Yes No
17. Does the test match the stage of screening, treatment, or recovery and the documented history of the individual beneficiary?
Yes No
18. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings
- Stage of treatment or recovery;
- Suspected abused substance;
- Substances that may present high risk for additive or synergistic interactions with prescribed medication (e.g., benzodiazepines, alcohol).
Yes No
19. Does the medical record include an appropriate testing frequency based on the stage of screening, treatment, or recovery. Is the rationale for the drugs/drug classes ordered documented and are the results in the medical record and used to direct care? (GROUP B)
Yes No
20. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings;
- Current treatment plan;
- Prescribed medication(s)
- Risk assessment
Yes No
21. If the frequency of testing is beyond the appropriate testing frequency, does the record document individual patient needs to substantiate the need for additional testing?
- Patient response to prescribed medication suddenly changes
- Patient side effect profile changes
- To assess for possible drug-drug interactions
- Sudden change in patient’s medical condition
- Patient admits to use of illicit or non-prescribed controlled substance.
Yes No
22. If testing is direct to definitive UDT, without a presumptive test, or done with negative presumptive, does the record contain an individualized treatment plan detailing the rationale and/or to detect a drug known not to be detected by presumptive testing?
Yes No
23. Was drug testing done on two different specimen types from the same patient on the same date of service for the same drug/metabolite/analytes?
Yes No
24. Was the drug test obtained for the purpose of specimen validity including, but not limited to pH, specific gravity, oxidants, creatine?
Yes No
25. Was the UDT for medico-legal and/or employment purposes or to protect a physician from drug diversion charges?
Yes No
17. Does the medical record reflect the clinician's rational for the defInitive UDT and tests ordered?
Yes No
18. Is the rationale for testing individualized & based on clinical history and risk assessment?
Yes No
19. Does the test match the stage of screening, treatment, or recovery and the documented history of the individual beneficiary?
Yes No
20. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings
- Stage of treatment or recovery;
- Suspected abused substance;
- Substances that may present high risk for additive or synergistic interactions with prescribed medication (e.g., benzodiazepines, alcohol).
Yes No
21. Does the medical record include an appropriate testing frequency based on the stage of screening, treatment, or recovery. Is the rationale for the drugs/drug classes ordered documented and are the results in the medical record and used to direct care? (GROUP B)
Yes No
22. Does the medical record reflect the following medical necessity guidance criteria:
- Patient history, physical examination, and previous laboratory findings;
- Current treatment plan;
- Prescribed medication(s)
- Risk assessment
Yes No
23. If the frequency of testing is beyond the appropriate testing frequency, does the record document individual patient needs to substantiate the need for additional testing?
- Patient response to prescribed medication suddenly changes
- Patient side effect profile changes
- To assess for possible drug-drug interactions
- Sudden change in patient’s medical condition
- Patient admits to use of illicit or non-prescribed controlled substance.
Yes No
24. If testing is direct to definitive UDT, without a presumptive test, or done with negative presumptive, does the record contain an individualized treatment plan detailing the rationale and/or to detect a drug known not to be detected by presumptive testing?
Yes No
25. Was drug testing done on two different specimen types from the same patient on the same date of service for the same drug/metabolite/analytes?
Yes No
26. Was the drug test obtained for the purpose of specimen validity including, but not limited to pH, specific gravity, oxidants, creatine?
Yes No
27. Was the UDT for medico-legal and/or employment purposes or to protect a physician from drug diversion charges?
Yes No
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