Hi, I'm Angela at the Centers for Medicare & Medicaid Services and today we will be discussing
laboratory and other diagnostic services provided outside of the hospital setting.
Medicare contractors such as the Comprehensive Error Rate Testing (or CERT) contractor, under
the direction of CMS, may request records to ensure appropriate payment of any billed
diagnostic service.
When you bill Medicare for reimbursement, you're responsible for obtaining, maintaining
and providing documentation to support every service billed.
And there are three important pieces to this puzzle.
Let's begin with orders.
An order is a communication from the treating physician or practitioner requesting a diagnostic
test.
The easiest way to make sure the order is done right is for the treating physician or
practitioner to submit a legibly signed and dated order or requisition form.
If the order isn't signed, it must have documentation to support the intent to order the laboratory
or diagnostic service.
If there's no signed order, the treating physician or practitioner must document his or her intent
to order the test in the medical record's signed progress or visit note.
The second piece of the puzzle is documentation showing that the test is medically necessary.
Even though you need to submit the ICD-10-CM code to show the disease process related to
the service, that doesn't count as documentation of medical necessity.
The treating physician or practitioner needs to be sure to indicate in the medical record
why the test is needed to manage that specific medical problem.
And, if you're responding to a CERT records request, make sure to include the results
of the diagnostic test billed.
Oh, and one important point.
It's your responsibility to communicate with the treating physician or practitioner to
get the documentation showing medical necessity.
The old saying if it wasn't documented, it wasn't done certainly holds true here and
brings us to our third piece of the puzzle.
The glue that holds the pieces together is the treating physician or practitioner's signature.
We all know that the signature should be legible and dated, but what do you need to do when
you can't read it, or there's no signature?
Let's start with an illegible signature.
If the signature is illegible, then submit a signature attestation or signature log.
Now, if the signature is missing, the treating physician or practitioner will need to complete
a signature attestation.
And here's an important point.
An attestation statement isn't an acceptable substitute for unsigned physician or practitioner
orders or requisitions.
So, before you provide a service, check carefully for authenticated records.
If the signature is missing from an order, CMS medical review entities shall disregard
the order during the review of the claim.
The order must be signed at the time of the order.
Finally, if the treating physician or practitioner uses electronic orders, he or she needs to
be sure to include a copy of his or her policy and procedures describing how the notes and
the orders are signed and dated.
It's important that the treating physician or practitioner enter the electronic system
with his or her own unique ID and password.
For more information, visit the CMS, CERT, and your Medicare Administrative Contractor
or MAC websites for further educational articles on orders, medical necessity and signature
requirements for diagnostic services.
Also, Check out the Lab Services Fact sheet on the cms.gov Provider Compliance page and
select the link for the CERT A/B MAC Task Force for this and other educational resources.
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