Physician Impact on Laboratory Service Providers

Recent Insufficient Documentation Error Data Showing Impact

The Comprehensive Error Rate Testing (CERT) contractor continues to identify errors for the clinical laboratory specialty associated with insufficient documentation. An insufficient documentation error occurs when there is not enough documentation submitted to the CERT contractor for them to determine the medical need for a service. The most common insufficient documentation error is due to missing a valid order/intent to order a service and/or documentation to support the medical need for an ordered service.

Services that are billed more frequently and with higher volumes will have a higher weight applied to them. This statistical methodology is used to estimate the payments that did not meet Medicare coverage, coding and billing rules for our nation. Please note, the extrapolated dollars are NOT the amount that was or will be recovered from providers but rather a reflection of how errors can affect the overall national improper payment rate.

November 2017

Clinical Laboratory (Billing Independently)

JFB Root Causes by Provider Type Error Weighted Error $
Imaging or Laboratory test - Missing physician order/intent and supportive documentation (i.e. lab results, diag rpts, visit notes, clinical documentation, etc.) 152 $12,712,453.26
Imaging or Laboratory test - Missing supportive documentation (i.e. daily notes, progress notes, evaluation, clinical documentation, etc.) 36 $10,084,278.34
No medical records were submitted 6 $1,670,400.59
Imaging or Laboratory test - Missing results/report and supportive documentation (i.e. clinical documentation, progress notes, evaluation, etc.) 4 $390,212.64
Imaging or Laboratory test - Missing results/report only 1 $305,900.78
Venipuncture - Documentation does not support medical necessity 2 $280,714.61
Imaging or Laboratory test - Documentation supports CPT/HCPCS code change 6 $121,613.21
Imaging or Laboratory test - Documentation does not support medical necessity 1 $104,317.93
Imaging or Laboratory test - Missing the physician order/intent only 6 $44,862.66
Grand Total 215 $33,128,270.97

What are the Documentation Requirements?

The treating physician must order all tests. Tests not ordered by the physician are not reasonable and necessary.

  • Documentation in patient's medical record must support medical necessity for ordering service(s). Submission of these medical records in response to a request for medical records is a requirement of participation with Medicare
  • Keep these records available upon request:
    • Progress notes or office notes that support order(s) and that are properly signed;
    • Physician order/intent to order with a proper signature;
    • Laboratory results and how results affected your care;
    • Attestation/signature log for illegible signature(s)

Signature Requirements

  • All orders and progress/clinical notes are to be signed by treating physician before being submitted to Medicare for review
  • Unsigned physician orders or unsigned requisitions do not support physician intent to order
  • Physicians should sign all orders for diagnostic services to avoid potential denials. If a lab test(s) is ordered in medical record and that order is properly signed, physician is not required to sign actual requisition form
  • If signature is missing on progress note which supports intent to order, ordering physician must complete an attestation statement and submit it with response. If signature is illegible, an attestation statement or signature log is acceptable. For an example of a signature attestation statement, visit CERT Provider website
  • Attestation statements are not acceptable for unsigned physician orders/requisitions

Ordering/Referring Services

Cooperation among ordering/referring providers and facilities that perform diagnostic tests is crucial to reducing errors and avoiding claim denials.

If you bill laboratory services to Medicare, you must obtain the treating physician's signed order (or signed progress note to support intent to order) and documentation to support medical necessity for the ordered service(s). These records may be housed at another location (for example, a nursing facility, hospital, or referring physician office).

Providers who order diagnostic services for Medicare patients must maintain documentation of the order/intent to order and medical necessity of the service(s) in the patient's medical record and provide copies of same upon request. This information must be available and submitted, along with the test results, upon request for a Medicare claim review. Additional information can be found in CMS Medicare Learning Network (MLN) Matters (MM)9112 - Clarification of Ordering and Certifying Documentation Maintenance Requirements.

Note: While a physician order should always be signed, the physician must clearly document in the medical record his or her intent that the test be performed.


Last Updated Dec 18 , 2023