Medical Review Frequently Asked Questions (FAQs)

Q1. When documentation is requested for a lab or other test (such as an x-ray, CT scan or endoscopy) does documentation from the ordering/referring provider need to be submitted as well? The ordering/referring provider may not be with/or located at the same facility.
A1. Yes. In addition to the lab/test report and order/requisition/intent to order, clinical notes from the ordering/referring provider is needed to support the reasonable medical necessity of the service provided. The clinical records must substantiate the diagnoses included on the claim/orders. The Social Security Act, the law governing Medicare, Section 1842(p)(4) mandates that:

In case of an item or service…ordered by a physician or a practitioner…but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner.

A letter is available to assist in obtaining documentation from the ordering/referring provider. Access the Dear Ordering/Referring Physician Letter from the Medical Review Educational Resources.

Q2. Does being homebound mean that a patient is automatically eligible for a home evaluation and management (E&M) visit?|
A2. No, just because a patient is homebound does not mean he/she automatically qualifies for a home E&M visit. A patient may be homebound because he/she has no vehicle, does not drive or does not have anyone available to drive him/her to appointments and other activities. For home services provided by a physician using these codes, the beneficiary does not need to be confined to the home. The medical record must document the medical necessity of the home visit made in lieu of an office or outpatient visit. See the CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12

Last Updated Sep 28, 2018