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Last Modified: 1/4/2022 Location: FL, PR, USVI Business: Part A, Part B

Checklist: Clinical labs

This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests pertaining to clinical lab drug testing. Health care providers retain responsibility to submit complete and accurate documentation.

Documentation requirements

Documentation to support a signed order for lab test or medical records to support the intent to order by the treating physician, (e.g., signed office visit note, signed progress note, or signed physician order/requisition)
Documentation to support the medical necessity of the lab tests ordered and frequency in accordance with all Medicare regulations and any applicable NCDs or jurisdiction N LCDs.
Documentation to include lab test results.
Signature attestation or signature log (for illegible signatures) from physician's progress notes supporting medical necessity or intent to order.
Disclaimer: This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in NCDs, LCDs, or the CMS documentation
It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission documentation.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.