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Part A Alabama CERT Findings for Insufficient Laboratory and/or Diagnostic Documentation

Cahaba GBA has recently experienced an increase in Comprehensive Error Rate Testing (CERT) errors for services determined to lack medical necessity.  Upon further research it appears that CERT is assigning these errors in situations where the documentation indicates laboratory services and/or diagnostic testing is performed without the required physician’s order. 

42 CFR 410.32 (a) requires, when billed to any contractor, all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary’s specific medical problem.  Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. 

Orders for diagnostic tests must be written and signed by the treating physician/ practitioner requesting the diagnostic test.  In addition to a written order with signature, documentation should include patient information, diagnosis, the name of the test(s), test results with interpretation and any additional supporting documentation that substantiates all of the services billed.  Appropriate documentation must be maintained to support the medical necessity of the service and the claim submitted. 

The treating physician/practitioner may also deliver an order by telephone call and by electronic mail.  If the order is communicated by telephone, both, the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records.

Upon request by the CERT Documentation Contractor, it is important that providers submit adequate documentation for diagnostic testing. 

The following examples of identified errors are being provided in an effort to offer some insight into what this contractor has observed in recent error feedback from CERT. 

 

Examples of Errors for Medically Unnecessary Service or Treatment

  • Billed Service: The provider billed CPT Code 80069 (Renal Function Panel)

    CERT Reviewer Comments: Missing signed physician’s order for renal function panel billed on date of service.  Submitted documentation includes “Standing Order” requisition unsigned by physician.
  • Billed Service: The provider billed CPT Code 85610 (Prothrombin Time)

    CERT Reviewer Comments: Submitted records for review consist of laboratory results for this billed test and progress notes from the Anticoagulation Clinic, which does not meet the criteria for a physician’s order.
  • Billed Service: The provider billed CPT Code 74170 (Computed tomography, abdomen; without contrast material, followed by contrast material(s) and further sections)

    CERT Reviewer Comments: There is no order by the treating physician or his office for CT scan of the abdomen, only a copy of a reservation for the outpatient test.
  • Billed Service: The provider billed CPT Code 80053 (Comprehensive Metabolic Panel)

    CERT Reviewer Comments: The lab requisition sheet was submitted but it has no physician signature.  There is no signed physician order for the billed comprehensive metabolic panel.
  • Billed Service: The provider billed CPT Code 83036 (Hemoglobin Glycosylated A1C)

    CERT Reviewer Comments: Missing signed physician's order for Hemoglobin A1C billed on date of service.  RN signed requisition submitted with verbal order - unsigned or validated by physician. 

For additional information regarding order requirements for diagnostic tests, refer to the following references:

  • CERT Report Data Globe to indicate www link. may be viewed by selecting the “CERT Reports” on the CMS Web site.

Page last updated: July 1, 2008