February 27, 2018 - Reviewed 11/19/21
How to Avoid Lab Errors
The majority of improper payments for laboratory services identified by the Comprehensive Error Rate Testing (CERT) Program were due to insufficient documentation. Insufficient documentation means that something was missing from the medical records. For example:
- 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
Important Reminders to Laboratories to Avoid Errors:
- 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).
- Medical Necessity MUST include treating physician’s note stating why tests are to be done along with ICD10.
- These records may be housed at another location (for example, a nursing facility, hospital, or referring physician office).
Important Reminders to Providers to Avoid Errors
- 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.
- 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,
- When completing progress notes, 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).
Important Signature Reminders:
CMS guidelines for using an electronic signature are:
- Systems and software products must include protections against modification, and you should apply administrative safeguards that correspond to standards and laws
- The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information being attested to
- Physicians are encouraged to check with their attorneys and malpractice insurers in regard to the use of alternative signature methods
- Part B providers must use a qualified electronic prescribing (e-prescribing) system
- Prescriptions for drugs incident to Durable Medical Equipment (DME) must be made via a qualified e-prescribing system
Unsigned physician orders or unsigned requisitions alone do not support physician intent to order.
- Attestation statements are not acceptable for unsigned physician orders/requisitions.
- 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
One avenue to protect the Medicare Trustfund from Fraud and Abuse is cooperation among ordering/referring providers and facilities that perform diagnostic tests and is crucial to reducing errors and avoiding claim denials.
References:
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