Medicare has identified a recent increase in the number of Comprehensive Error Rate Testing (CERT) claims errors attributed to the lack of documentation in the treating (ordering) physician’s patient record for diagnostic testing.
Medicare defines a Diagnostic Test as:
And, further defines Clinical Laboratory Services as:
To avoid denials, the testing facilities and physician's offices need to work together.
Testing facilities should attempt to obtain a physician's order at the time the beneficiary presents to the facility for the diagnostic test. This can be accomplished by directing the beneficiary to bring a prescription that includes the condition or diagnosis for which the diagnostic test is ordered, along with the physician's order.
If the beneficiary presents without a valid order, the testing facility should call the treating (ordering) physician's office to obtain a telephone order for the diagnostic test.
Note: Make sure to document the telephone call in the testing facility and treating (ordering) physician's copies of the beneficiary's medical records.
The treating (ordering) physician must clearly document, in the medical record, their intent that the test be performed, and documentation supporting medical necessity for the ordered test.
Failure to provide proper documentation may result in denial of the service, which may lead to the patient being responsible for payment.
The absence of a signature on an order may lead to a medical record audit to verify that the physician's intent is documented as directed in the regulation. Therefore, it is recommended that physicians sign all orders for diagnostic and laboratory services, and appropriately document the patient’s record.
The Centers for Medicare & Medicaid Services (CMS) defines an order as:
“A communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y)."
Although CMS does not require the order to be signed by the physician, the treating (ordering) physician must clearly document in the beneficiary's record the intent to order the diagnostic test, and document the medical necessity supporting the ordered service.
An order may be delivered as:
Note: If the order is communicated by telephone, both the treating (ordering) physician’s/practitioner’s office and the testing facility must document the telephone call in their respective copies of the beneficiary's medical record.
While a treating (ordering) physician's order is not required to be signed for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services; the treating (ordering) physician must clearly document, in the medical record, their intent that the test be performed, and documentation supporting medical necessity.
Documentation requested by either the CERT contractor or Novitas to support the order for the diagnostic test (or the physician's intent to order), will be sent to the testing facility since they are billing for the test. Often the testing facility is unable to provide the physician's order or intent to order because the information is in the beneficiary's record at the treating (ordering) physician's office. However, in order to be paid for the service, the testing facility must request the information from the treating (ordering) physician. Without the order or the intent to order, payment for the diagnostic test or service will be denied.
It is our goal to have claims paid correctly and to lower the CERT rate.
CMS Internet Only Manual, Publication 100-02, Benefit Policy Manual, Chapter 15, Sections 80 & 80.6