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Complying with Laboratory Services Documentation …
Page 1 of 5 Complying WITH Laboratory Services Documentation REQUIREMENTSICN MLN909221 December 2020 PRINT-FRIENDLY VERSIONMLN Fact SheetComplying with Laboratory Services Documentation RequirementsICN MLN909221 December 2020 Page 2 of 5 UPDATESNote: We revised this product with the following content updates: Clarified Documentation requirements to add language acceptable to Medical Review Contractors auditing records for regulatory guidance compliance Added clarification to the term standing orders MLN Fact SheetComplying with Laboratory Services Documentation RequirementsICN MLN909221 December 2020 Page 3 of 5 INTRODUCTIONThe majority of improper Laboratory Services payments identified by the Comprehensive Error Rate Testing (CERT) Program are due to insufficient Documentation . Insufficient Documentation means something is missing from the medical records. Examples include: Documentation to support intent to order, such as a signed progress note, signed office visit note, or signed physician order Documentation to support the medical necessity of ordered servicesRemember the following tips to help you avoid requirements The physician who treats a patient must order all diagnostic x-rays, diagnostic Laboratory tests, and other diagnostic tests for a specific medical problem.
DOCUMENTATION REQUIREMENTS The physician who treats a patient must order all diagnostic x-rays, diagnostic laboratory tests, and other diagnostic tests for a specific medical problem. The physician uses test results to manage the patient’s specific medical problem and may provide a consultation. Tests not ordered by the physician
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