Incorrect Laboratory Services Billing Identified by MR and CERT

Noridian's Medical Review Team and the Comprehensive Error Rate Testing (CERT) Contractor have identified multiple errors regarding incorrect billing of laboratory services. Laboratory medical records are requested to determine correct billing and coverage under Medicare guidelines.

Coverage and Documentation

Diagnostic X-ray, laboratory, and other diagnostic tests, including materials and the services of technicians, are covered under the Medicare program. When the hospital obtains laboratory tests for outpatients under arrangements with clinical laboratories or other hospital laboratories, only the hospital can bill for the arranged services. The hospital or entity providing the laboratory test must obtain, maintain and submit all documentation to support laboratory services.

Tests not ordered by the physician who is treating the beneficiary are not reimbursed. Although no signature is required on an order form for a clinical diagnostic test paid on the Laboratory Fee Schedule, the medical record and/or the request itself must clearly document the physician's intent for the diagnostic test to be performed.

Common coding and billing errors identified:

  • Entity performs and bills the Current Procedural Terminology (CPT) 85025 (Complete Blood Count(CBC), with differential White Blood Count (WBC) automated)
    • Physician order or intent supports only CPT 85027 (CBC, automated)
  • Entity performs and bills CPT 81001 Urinalysis automated (UA), with microscopy
    • Physician order or intent only supports only UA 81003
  • Physician's order not authenticated  (unreadable or indecipherable)
    • Physician's illegible signature on the progress/office note or order/intent was not supported by the signature log or attestation

In all examples above, the entity should have only performed and billed for the services indicated on the order, rather than the additional services completed per internal protocols. Protocols are not accepted by Medicare as orders. Noridian encourages facilities to set internal controls to ensure these additional services are not being performed unless indicated in the physician order.

Though the dollar amounts associated with these CERT findings are small, they do extrapolate out to a very high dollar amount when applied across the Medicare claims universe. This in turn, creates a higher CERT error rate associated with these lab services.



Last Updated Nov 18 , 2022