CMS Documentation Reminder to Physicians Ordering Lab Services

Recent results from the Comprehensive Error Rate Testing (CERT) Program revealed that the majority of improper payment for laboratory service result from insufficient documentation.  This article summarizes important documentation recommendations from CMS.

The type of missing information identified by CERT audits included a lack of a signed physician order, lack of progress notes to support intent to order (e.g., lack of visit note), or lack of documentation to support medical necessity.  In response to the CERT audit results, CMS has made several documentation recommendations to improve physician documentation.

1) When completing progress notes, for example, physicians should “clearly indicate all tests to be performed.” CMS noted that statements such as “run labs” or “check blood” alone do not support intent.

2) Patient’s medical records also must contain documentation to support the medical necessity for ordering the service(s) per Medicare regulations and applicable Local Coverage Determinations (LCDs). CMS advised that physicians and staff should regularly check the NCDs and LCDs for any updates.

3) Physicians should sign all orders for diagnostic services to avoid potential denials. Signatures must be legible and include the first and last name. Unsigned physician orders or unsigned requisitions alone do not support physician intent. Where progress notes are missing a signature, CMS has said that physicians should submit an attestation statement in response to medical records review request. Attestation statements, however, warned CMS, will not be accepted in lieu of an unsigned physician orders/requisitions.

4) Ordering practitioners who order diagnostic services for Medicare patients should maintain documentation of the order/intent to order, medical necessity of the service(s), and the results in the patient’s medical record and make them available upon request.

If you have questions regarding ordering/referring lab services for Medicare patients, Medicare enrollment or revalidation, or have other heath care law question, please contact our office.