Lab Services/Orders Documentation Review Decision Tree
1. Has your patient’s diagnosis been documented?
Be sure you included in your documentation the reason the patient needs the test ordered (Medical Necessity) and not just the ICD-10 code.
Complying with Documentation Requirements for Laboratory Services
2. Was your decision for this lab test documented?
An authenticated medical record that supports the physician/practitioner's intent to order tests (e.g. order labs, check blood, repeat urine)
Complying with Documentation Requirements for Laboratory Services
3. Has your order been signed by the treating provider?
There are some circumstances for which an order does not need to be signed (i.e. orders for clinical diagnostic tests are not required to be signed) however, there must be medical documentation by the treating physician that he/she intended the clinical diagnostic test be performed. This documentation showing the intent must be authenticated by the author. There MUST be a signature on either the order or the intent. IOM 100-08 Program Integrity Manual, Chapter 3, sec 3.3.2.4 Signature Requirements.
IOM 100-08 Program Integrity Manual, Chapter 3, sec 3.3.2.4 Signature Requirements
4. Was your test ordered for the treatment of the individual patient?
5. Was the order transmitted via Written Documentation?
Documentation that is signed by the treating physician/eligible professionals, which is hand-delivered, mailed, or faxed to the testing facility. Although no signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services, documentation in the medical record must show intent to order and medical necessity for the testing.
MLN Fact Sheet: Provider Compliance Tips for Lab Tests - Other (non-Medicare fee schedule)
6. Was the order transmitted via Telephone?
The treating physician/eligible professional or his/her office to the testing facility; If the order is communicated via telephone, both the treating physician/eligible professional or his/her office and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records. This documentation MUST be signed upon the provider’s next visit to the facility.
MLN Fact Sheet: Provider Compliance Tips for Lab Tests - Other (non-Medicare fee schedule)
7. Was the order transmitted via Electronic Mail?
This method can be used to send to the testing facility by the treating physician/eligible professional or his/her office. MUST contain an electronic signature.
MLN Fact Sheet: Provider Compliance Tips for Lab Tests - Other (non-Medicare fee schedule)
8. Does your order meet Medicare Guidelines?
Routine orders are orders for those services and treatments that are applied to patients who have the same or similar medical condition(s). These frequently called "routine, protocol or standing orders" are based on an assessment of the impact of a given condition in the population of patients with that condition (medical illness or injury) and are widely applied to those patients.
Medicare defines any order(s) that does not specifically address an individual patient's unique illness, injury or medical status, as not reasonable and necessary. As is required by law, Medicare does not accept such "standing orders" as supporting medical necessity for the individual patient. Services related to population-based or condition-based orders are not reimbursable.
Each ordered test must be appropriate and necessary for the treatment of the individual patient on a specific date of service.
The frequency and number of repeated testing must not be greater than medically necessary.
The diagnosis must be indicated for each test with sufficient clarity to permit accurate ICD-10-CM coding to the highest level of specificity.
All lab tests must be reviewed and documentation must support that the appropriate clinical action was taken.
Each result must be reviewed with appropriate action taken by the treating physician, including any appropriate change in the frequency or duration of testing
Preprinted orders are not covered by Medicare. However, preprinted or electronic lists of potential orders are permitted if the provider individually affirms, defines, or otherwise modifies each component as appropriate for an individual patient’s clinical circumstances.
Treatment protocols may be reimbursable since these protocols are individualized to each patient. For example, the use of chemotherapeutic drug protocols that suggest drugs, dosage ranges, frequency and/or duration specifically ordered for an individual patient
8. Does your order meet Medicare Guidelines?
Routine orders are orders for those services and treatments that are applied to patients who have the same or similar medical condition(s). These frequently called "routine, protocol or standing orders" are based on an assessment of the impact of a given condition in the population of patients with that condition (medical illness or injury) and are widely applied to those patients.
Medicare defines any order(s) that does not specifically address an individual patient's unique illness, injury or medical status, as not reasonable and necessary. As is required by law, Medicare does not accept such "standing orders" as supporting medical necessity for the individual patient. Services related to population-based or condition-based orders are not reimbursable.
Each ordered test must be appropriate and necessary for the treatment of the individual patient on a specific date of service.
The frequency and number of repeated testing must not be greater than medically necessary.
The diagnosis must be indicated for each test with sufficient clarity to permit accurate ICD-10-CM coding to the highest level of specificity.
All lab tests must be reviewed and documentation must support that the appropriate clinical action was taken.
Each result must be reviewed with appropriate action taken by the treating physician, including any appropriate change in the frequency or duration of testing
Preprinted orders are not covered by Medicare. However, preprinted or electronic lists of potential orders are permitted if the provider individually affirms, defines, or otherwise modifies each component as appropriate for an individual patient’s clinical circumstances.
Treatment protocols may be reimbursable since these protocols are individualized to each patient. For example, the use of chemotherapeutic drug protocols that suggest drugs, dosage ranges, frequency and/or duration specifically ordered for an individual patient
7. Was the order transmitted via Electronic Mail?
This method can be used to send to the testing facility by the treating physician/eligible professional or his/her office. MUST contain an electronic signature.
MLN Fact Sheet: Provider Compliance Tips for Lab Tests - Other (non-Medicare fee schedule)
8. Does your order meet Medicare Guidelines?
Routine orders are orders for those services and treatments that are applied to patients who have the same or similar medical condition(s). These frequently called "routine, protocol or standing orders" are based on an assessment of the impact of a given condition in the population of patients with that condition (medical illness or injury) and are widely applied to those patients.
Medicare defines any order(s) that does not specifically address an individual patient's unique illness, injury or medical status, as not reasonable and necessary. As is required by law, Medicare does not accept such "standing orders" as supporting medical necessity for the individual patient. Services related to population-based or condition-based orders are not reimbursable.
Each ordered test must be appropriate and necessary for the treatment of the individual patient on a specific date of service.
The frequency and number of repeated testing must not be greater than medically necessary.
The diagnosis must be indicated for each test with sufficient clarity to permit accurate ICD-10-CM coding to the highest level of specificity.
All lab tests must be reviewed and documentation must support that the appropriate clinical action was taken.
Each result must be reviewed with appropriate action taken by the treating physician, including any appropriate change in the frequency or duration of testing
Preprinted orders are not covered by Medicare. However, preprinted or electronic lists of potential orders are permitted if the provider individually affirms, defines, or otherwise modifies each component as appropriate for an individual patient’s clinical circumstances.
Treatment protocols may be reimbursable since these protocols are individualized to each patient. For example, the use of chemotherapeutic drug protocols that suggest drugs, dosage ranges, frequency and/or duration specifically ordered for an individual patient
8. Does your order meet Medicare Guidelines?
Routine orders are orders for those services and treatments that are applied to patients who have the same or similar medical condition(s). These frequently called "routine, protocol or standing orders" are based on an assessment of the impact of a given condition in the population of patients with that condition (medical illness or injury) and are widely applied to those patients.
Medicare defines any order(s) that does not specifically address an individual patient's unique illness, injury or medical status, as not reasonable and necessary. As is required by law, Medicare does not accept such "standing orders" as supporting medical necessity for the individual patient. Services related to population-based or condition-based orders are not reimbursable.
Each ordered test must be appropriate and necessary for the treatment of the individual patient on a specific date of service.
The frequency and number of repeated testing must not be greater than medically necessary.
The diagnosis must be indicated for each test with sufficient clarity to permit accurate ICD-10-CM coding to the highest level of specificity.
All lab tests must be reviewed and documentation must support that the appropriate clinical action was taken.
Each result must be reviewed with appropriate action taken by the treating physician, including any appropriate change in the frequency or duration of testing
Preprinted orders are not covered by Medicare. However, preprinted or electronic lists of potential orders are permitted if the provider individually affirms, defines, or otherwise modifies each component as appropriate for an individual patient’s clinical circumstances.
Treatment protocols may be reimbursable since these protocols are individualized to each patient. For example, the use of chemotherapeutic drug protocols that suggest drugs, dosage ranges, frequency and/or duration specifically ordered for an individual patient
6. Was the order transmitted via Telephone?
The treating physician/eligible professional or his/her office to the testing facility; If the order is communicated via telephone, both the treating physician/eligible professional or his/her office and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records. This documentation MUST be signed upon the provider’s next visit to the facility.
MLN Fact Sheet: Provider Compliance Tips for Lab Tests - Other (non-Medicare fee schedule)
7. Was the order transmitted via Electronic Mail?
This method can be used to send to the testing facility by the treating physician/eligible professional or his/her office. MUST contain an electronic signature.
MLN Fact Sheet: Provider Compliance Tips for Lab Tests - Other (non-Medicare fee schedule)
8. Does your order meet Medicare Guidelines?
Routine orders are orders for those services and treatments that are applied to patients who have the same or similar medical condition(s). These frequently called "routine, protocol or standing orders" are based on an assessment of the impact of a given condition in the population of patients with that condition (medical illness or injury) and are widely applied to those patients.
Medicare defines any order(s) that does not specifically address an individual patient's unique illness, injury or medical status, as not reasonable and necessary. As is required by law, Medicare does not accept such "standing orders" as supporting medical necessity for the individual patient. Services related to population-based or condition-based orders are not reimbursable.
Each ordered test must be appropriate and necessary for the treatment of the individual patient on a specific date of service.
The frequency and number of repeated testing must not be greater than medically necessary.
The diagnosis must be indicated for each test with sufficient clarity to permit accurate ICD-10-CM coding to the highest level of specificity.
All lab tests must be reviewed and documentation must support that the appropriate clinical action was taken.
Each result must be reviewed with appropriate action taken by the treating physician, including any appropriate change in the frequency or duration of testing
Preprinted orders are not covered by Medicare. However, preprinted or electronic lists of potential orders are permitted if the provider individually affirms, defines, or otherwise modifies each component as appropriate for an individual patient’s clinical circumstances.
Treatment protocols may be reimbursable since these protocols are individualized to each patient. For example, the use of chemotherapeutic drug protocols that suggest drugs, dosage ranges, frequency and/or duration specifically ordered for an individual patient
8. Does your order meet Medicare Guidelines?
Routine orders are orders for those services and treatments that are applied to patients who have the same or similar medical condition(s). These frequently called "routine, protocol or standing orders" are based on an assessment of the impact of a given condition in the population of patients with that condition (medical illness or injury) and are widely applied to those patients.
Medicare defines any order(s) that does not specifically address an individual patient's unique illness, injury or medical status, as not reasonable and necessary. As is required by law, Medicare does not accept such "standing orders" as supporting medical necessity for the individual patient. Services related to population-based or condition-based orders are not reimbursable.
Each ordered test must be appropriate and necessary for the treatment of the individual patient on a specific date of service.
The frequency and number of repeated testing must not be greater than medically necessary.
The diagnosis must be indicated for each test with sufficient clarity to permit accurate ICD-10-CM coding to the highest level of specificity.
All lab tests must be reviewed and documentation must support that the appropriate clinical action was taken.
Each result must be reviewed with appropriate action taken by the treating physician, including any appropriate change in the frequency or duration of testing
Preprinted orders are not covered by Medicare. However, preprinted or electronic lists of potential orders are permitted if the provider individually affirms, defines, or otherwise modifies each component as appropriate for an individual patient’s clinical circumstances.
Treatment protocols may be reimbursable since these protocols are individualized to each patient. For example, the use of chemotherapeutic drug protocols that suggest drugs, dosage ranges, frequency and/or duration specifically ordered for an individual patient
7. Was the order transmitted via Electronic Mail?
This method can be used to send to the testing facility by the treating physician/eligible professional or his/her office. MUST contain an electronic signature.
MLN Fact Sheet: Provider Compliance Tips for Lab Tests - Other (non-Medicare fee schedule)
8. Does your order meet Medicare Guidelines?
Routine orders are orders for those services and treatments that are applied to patients who have the same or similar medical condition(s). These frequently called "routine, protocol or standing orders" are based on an assessment of the impact of a given condition in the population of patients with that condition (medical illness or injury) and are widely applied to those patients.
Medicare defines any order(s) that does not specifically address an individual patient's unique illness, injury or medical status, as not reasonable and necessary. As is required by law, Medicare does not accept such "standing orders" as supporting medical necessity for the individual patient. Services related to population-based or condition-based orders are not reimbursable.
Each ordered test must be appropriate and necessary for the treatment of the individual patient on a specific date of service.
The frequency and number of repeated testing must not be greater than medically necessary.
The diagnosis must be indicated for each test with sufficient clarity to permit accurate ICD-10-CM coding to the highest level of specificity.
All lab tests must be reviewed and documentation must support that the appropriate clinical action was taken.
Each result must be reviewed with appropriate action taken by the treating physician, including any appropriate change in the frequency or duration of testing
Preprinted orders are not covered by Medicare. However, preprinted or electronic lists of potential orders are permitted if the provider individually affirms, defines, or otherwise modifies each component as appropriate for an individual patient’s clinical circumstances.
Treatment protocols may be reimbursable since these protocols are individualized to each patient. For example, the use of chemotherapeutic drug protocols that suggest drugs, dosage ranges, frequency and/or duration specifically ordered for an individual patient
8. Does your order meet Medicare Guidelines?
Routine orders are orders for those services and treatments that are applied to patients who have the same or similar medical condition(s). These frequently called "routine, protocol or standing orders" are based on an assessment of the impact of a given condition in the population of patients with that condition (medical illness or injury) and are widely applied to those patients.
Medicare defines any order(s) that does not specifically address an individual patient's unique illness, injury or medical status, as not reasonable and necessary. As is required by law, Medicare does not accept such "standing orders" as supporting medical necessity for the individual patient. Services related to population-based or condition-based orders are not reimbursable.
Each ordered test must be appropriate and necessary for the treatment of the individual patient on a specific date of service.
The frequency and number of repeated testing must not be greater than medically necessary.
The diagnosis must be indicated for each test with sufficient clarity to permit accurate ICD-10-CM coding to the highest level of specificity.
All lab tests must be reviewed and documentation must support that the appropriate clinical action was taken.
Each result must be reviewed with appropriate action taken by the treating physician, including any appropriate change in the frequency or duration of testing
Preprinted orders are not covered by Medicare. However, preprinted or electronic lists of potential orders are permitted if the provider individually affirms, defines, or otherwise modifies each component as appropriate for an individual patient’s clinical circumstances.
Treatment protocols may be reimbursable since these protocols are individualized to each patient. For example, the use of chemotherapeutic drug protocols that suggest drugs, dosage ranges, frequency and/or duration specifically ordered for an individual patient
The physician who treats the beneficiary is the physician who furnishes a consultation, treats a beneficiary for a specific medical problem, and uses the results in the management of the beneficiary’s specific medical problem. CGS suggests reviewing your documentation in detail to ensure requirements are met.
MLN Fact Sheet: Provider Compliance Tips for Lab Tests - Other (non Medicare fee schedule)
Medicare coverage extends to tests ordered by a licensed provider (i.e. MD, DO, NP, PA). The physician or other eligible professional who is treating the beneficiary MUST order AND sign all diagnostic laboratory tests if reviewed and the signature is missing your claim will be denied for signature issues. 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).
IOM 100-08 Program Integrity Manual, Chapter 3, sec 3.3.2.4 Signature Requirements
Documentation MUST include the treating provider's decision, and changes that occurred that warrants the lab test ordered, if reviewed the claim will be denied for missing this information.
Complying with Documentation Requirements for Laboratory Services
Documentation MUST include the reason the patient needs the test ordered (Medical Necessity) and not just the ICD10 code diagnosis, if reviewed the claim will be denied for missing this information.
Complying with Documentation Requirements for Laboratory Services