Diagnostic Laboratory Services Targeted Probe and Educate Review Results - JE Part A
Diagnostic Laboratory Services Targeted Probe and Educate Review Results
The Jurisdiction E, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review on a variety of diagnostic laboratory services. The findings of the claims reviewed from April 1, 2025 through June 30, 2025 are as follows:
Review Results
- 454 claims were reviewed with 11.8% error rate
Top Trending Errors
- Documentation to support medical necessity
- Documentation to support services rendered
Educational Resources
- Laboratory Documentation Requirements
- Laboratory
- IOM, Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 80.6.1
- MCD Search
Education
Lipid Testing Frequency
Per the limitations in the National Coverage Determination (NCD) for Lipid Testing (190.23), Medicare does not cover routine screening and prophylactic testing. Any one component of the panel may be medically necessary up to six times the first year. More frequent monitoring may be indicated for marked elevations or changes to anti-lipid therapy. If no dietary or pharmacological therapy is advised, monitoring is not necessary. When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it is reasonable to perform the lipid panel annually.
A lipid panel is generally indicated no more than two times per year for evaluation of non-specific chronic liver findings, such as elevated liver function tests.
Thyroid Testing Medical Necessity
Per the National Coverage Determination (NCD) 190.22, thyroid lab tests may be reasonable to detect the presence or absence of hormonal abnormalities of the thyroid gland. Thyroid testing may be appropriate to:
- Confirm or rule out hypothyroidism/hyperthyroidism
- Monitor thyroid levels in patients with thyroid disease (thyroid cancer, goiter or nodules)
- To monitor therapy in patients with hypothyroidism/hyperthyroidism
Thyroid function testing may be medically necessary in a variety of situations. Medical documentation from the ordering provider should reflect the medical rational for thyroid testing.
Additional medical necessity rationales for thyroid function testing can be found in NCD 190.22.
Documentation to Support Medical Necessity
The practitioner that orders a service must maintain documentation to support medical necessity for that service in the beneficiary’s medical record. It is the responsibility of the provider submitting the claim to maintain documentation that is received and that it reflects the information received from the ordering practitioner. The submitting provider may request additional information from the ordering practitioner to support the service billed is reasonable and necessary as laid out in the Social Security Act 1862.
Upon receipt of the Additional Development Request (ADR), the billing provider must submit documentation of an order for the service, which includes information to identify and contact the ordering practitioner, to verify appropriate completion of the order and services billed.
For additional information on record keeping supporting medical necessity of billed claims, refer to 42 Code of Federal Registry (CFR) section 410.32.
Documentation Supporting Services Rendered
Under section 1833(e), Title XVIII of the Social Security Act (SSA) states, "no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period."
No Medicare payment can be made for claims that lack the necessary information for processing. Medicare claims will be allowed to process, when there is sufficient documentation in the patient’s records to verify the services were performed and were medically necessary and reasonable for the medical condition. Justification for the service may be documented in the physician’s clinic or hospital progress notes and/or laboratory results. If there is no documentation, or insufficient documentation to support the service, then Medicare considers the service not rendered and services will be denied.
