Corporate

October 24, 2014

Documentation for Diagnostic Services

Diagnostic tests, like all other services provided to Medicare patients, must be documented in patients’ medical records and copies provided to CGS (or another CMS-contracted entity) upon request.  Please keep in mind the following documentation requirements for diagnostic services:

  • Diagnostic tests may only be ordered by the “treating physician/practitioner.”
  • Unsigned orders or requisitions will NOT be considered in a review.
    • With few exceptions, Medicare requires that ALL medical records contain a legible provider signature.
    • If the signature on a progress note is missing or illegible, the physician or nonphysician practitioner who provided the service may complete an attestation statement, which should be submitted along with all other supporting documentation, if requested.  You may use CGS’s suggested attestation statementPDF (optional) or another one of your choosing, as long as it meets Medicare requirements.
  • Attestation statements are NOT acceptable for unsigned physician’s orders.
  • The treating physician should clearly indicate ALL tests to be performed in the patient’s medical records – simply stating “ordered x-rays” or “requested labs” is not acceptable.
  • The medical records MUST support the medical necessity of ordering the service and must be available for submission upon request.

If you are performing the diagnostic test, please keep in mind that it is your responsibility to obtain the treating physician’s order and documentation to support the medical necessity of the ordered service.  This includes any records from a third party (e.g., nursing facility, hospital, referring physician’s office).

Ordering providers MUST also maintain documentation of the order and medical necessity in the beneficiary’s medical record. This documentation should also be available upon request.

Most importantly – cooperation between the ordering/referring providers and providers who perform the diagnostic services is crucial in order to prevent denials.

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