Drug Testing/Screenings Documentation - JE Part B

The Comprehensive Error Rate Testing (CERT) contractor has identified findings related to the Controlled Substance Monitoring and Drugs of Abuse Testing Local Coverage Determination (LCD).

Documentation supplied for the CERT review is missing clinical documentation supporting medical necessity of the drug testing/screening billed such as documentation of suspected illicit drug use or non-compliance and/or documentation outlining the physicians' observations and rationale as to why a drug test/screening is needed.

CMS Internet Only Manual (IOM), Publication 100-08, Chapter 1, Section 1.3.7 indicates that SSA Section 1862(a)(1) states no Medicare payment shall be made for expenses incurred for items or services that "are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member;". Additionally, CMS IOM, Publication 100-08, Chapter 3, Section 3.3.2.1 states: "For Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met."

To help avoid improper payments, providers are encouraged to:

• Have an intake process to assess required elements per the Controlled Substance Monitoring and Drugs of Abuse Testing, LCD. See associated Coding Guidelines at end of LCD
• Supply attestations or signature logs for illegible signatures
• Ensure authenticated physician order is included or there is sufficient documentation in patients' medical record proving intent to order as a requisition alone typically does not support intent to order
• Document or obtain documentation that clearly and thoroughly includes all required elements. Documentation must include physician rationale, patient symptoms and all other observations used to determine appropriate care and course of action for a patient
• Contact ordering/referring physicians if/when insufficient documentation is received to support service billed