Physician ordering laboratory tests: Your vital role in submitting documentation
Physicians who order laboratory tests for Medicare beneficiaries play a vital role in validating medical necessity of these services. For clinical laboratory 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.
Clinical laboratories often bill for diagnostic tests for which First Coast or other Medicare contractors issue additional documentation requests to verify medical necessity. The clinical laboratory must attempt to obtain the medical order at the time the beneficiary appears at the 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 laboratory's responsibility to obtain and submit medical documentation for the billed test(s) to First Coast or other Medicare contractors when requested, they are often unable to provide this important documentation from the medical records because the information is with the ordering doctor’s office or practice. In these cases, for the laboratory to receive payment, they must request the information from the doctor ordering 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 laboratory in case it is requested. Without sufficient information from your medical records, the laboratory may use an Advance notice of non-coverage (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. Laboratories are your ally 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 laboratory that will provide the services to your patient may request additional diagnosis and medical information from the order to document that the billed services are reasonable and necessary. If the entity requests additional documentation, it 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 First Coast or other Medicare contractors does not violate the Health Insurance Portability and Accountability Act (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 required. 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). Please also refer to the article published by CMS titled Collaborative patient care is a provider partnership.
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