Laboratory and Pathology Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

Check box if submitted Requested Records (as applicable)
  Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  Practitioner, nurse, and ancillary progress notes
  Test results
  Physician/Non Physician (NPP) order or evidence of intent to Order
  Physician referral (prescription, treatment or diagnostic test)
  Signed requisitions for lab services
  Clinical information supplied to the lab by the ordering physician, including diagnosis codes and narratives
  Documentation from the prescribing/ordering physician
  History and Physical reports (include medical history and current list of medications)
  Interpretive statement, which specifically explains the test results and how it will be used in the beneficiary's care
  Documentation that supports the clinical significance of the test performed
  CLIA certificate
  You may utilize the “Dear Ordering Referring Physician” letter to obtain records from an outside facility. The letter is located on our website at https://med.noridianmedicare.com/
  Documentation supporting the diagnosis code(s) required for the item(s) billed
  Documentation to support the code(s) and modifier(s) billed
  List of all non-standard abbreviations or acronyms used, including definitions
  Other pertinent information
  Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  Signature attestation and credentials of all personnel providing services
  If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
  Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)

 

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part B Claim Review for detailed information about each of these contractors.

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Laboratory webpage for more information and resources.

 

Last Updated Wed, 01 Sep 2021 14:16:30 +0000

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.