Laboratory and Diagnostic Services: Documentation Responsibilities

When National Government Services is conducting a pre-pay or post-pay review of claims and services, we may request additional documentation. The billing provider must obtain supporting documentation (for example, physician’s order or notes to support medical necessity) from a referring physician’s office or from an inpatient facility, skilled nursing facility, or other location where records (for example, progress notes) are kept in order to support the services billed, ordered, or provided. 

The billing provider shall submit the requested documentation because they are the entity whose payment is being reviewed. 

Medicare covers medically necessary services, but patient medical record documentation must support the medical necessity. Instruct medical record staff and third-party medical record copy services to provide all records that support payment. This may include records for services before the date of service listed on the medical record request.

Examples include:

• A signed office note from a previous visit where the provider ordered a diagnostic or other service 
• For incident to services, the care plan written by the supervising physician or nonphysician practitioner 
• Lab orders for recurring tests to meet the specific needs of an individual patient

Physician Ordering Diagnostic and Laboratory Tests: Your Vital Role in Submitting Documentation

Physicians who order diagnostic or laboratory tests for Medicare beneficiaries play a vital role in validating medical necessity of the services. For these tests to be covered by Medicare, the medical record must contain enough information about the patient's condition to support the medical necessity of the tests.

Providers/laboratories often bill for diagnostic tests for which NGS (as the MAC), may issue ADRs to verify medical necessity. The performing provider/clinical laboratory must attempt to obtain the medical order at the time the beneficiary appears at their facility to receive the test(s). They can do this by asking the beneficiary to submit the medical order that includes the related diagnosis.

While it is the responsibility of the performing provider/clinical laboratory to obtain and submit medical documentation for the billed test(s) to NGS when requested, they are often unable to provide this important documentation from the medical records because it’s with the ordering doctor’s office or practice. In these cases, for the performing provider/clinical laboratory to receive payment, they must request the information from the doctor who ordered the test(s). Without the order or documentation such as progress notes indicating the intent to order the test(s), as well as supporting medical necessity, payment for the service(s) will be denied.

How Physicians Can Help

The physician or practitioner who orders the test(s) plays a vital role in providing medical documentation to the performing provider/clinical laboratory in case it is requested. Without sufficient information from your medical records, the performing provider/clinical laboratory may use an ABN which in turn may result in the patient being liable if services are denied.

To avoid denials, laboratories and medical offices need to work together as the performing provider/laboratory is your partner in your patient care. Providing this information is within the requirements of federal law, which requires providers to submit documentation supporting the medical necessity of services billed to Medicare. The performing provider/clinical laboratory that will provide the services to your patient may request additional diagnosis and medical information from your office to document that the billed services are reasonable and necessary. If the performing/billing entity requests additional documentation, they must request material relevant to the medical necessity of the specific test(s), taking into consideration the current rules and regulations on patient confidentiality.

In addition, providing medical records of Medicare patients to NGS does not violate the HIPAA Privacy Rule. Patient authorization is not required to respond to this request for documentation. Please note that you must provide documentation regarding the date of the service(s) and/or any prior progress notes if requested. 

Related Content

• MLN® Fact Sheet: Complying with Medical Record Documentation Requirements 
• MLN® Booklet: Medicare Advance Written Notices of Non-coverage
• MLN® Fact Sheet: Collaborative Patient Care is a Provider Partnership
• Additional Development Requests 
• For more information about the authorization for the disclosure of this information, refer to the Code of Federal Regulations 42 CFR §424.5(a) (6).

Posted 9/19/2024