Checklist: Clinical labs
| Check |
Documentation description |
|---|---|
| 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 national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.