Proper Documentation for Pathology and Laboratory Reports
A provider must document in the patient’s medical record medical necessity for pathology and laboratory services, as well as indicate that he or she ordered the tests. The ordering physician must also note in the patient’s record how he or she used the findings to select a diagnosis and a treatment plan.
The most commonly performed pathology and laboratory services require a physician to collect a specimen for testing and send it to an outside lab. The outside lab can be a hospital outpatient laboratory or an independent laboratory. The lab conducts the ordered test and sends a report back to the physician.
Because most tests are computerized, the results usually are reported by a number value on a computer printout. It is not sufficient to copy that number value into the patient’s chart or attach the computer printout to the patient record. Instead, the physician must note the type of test, the methodology used, the normal range for the test, and then comment on whether the finding is abnormal or normal in relation to that range. When the lab report reveals an abnormal finding, the physician should circle and sign the abnormal result to indicate he or she saw it. The physician must also make sure to address the abnormality in the diagnosis and treatment plan.
When the specimen is sent to an outside facility for testing, the lab performing the test should bill the service. Outpatient hospital laboratories are reimbursed based on a fee schedule for Medicare.
The lab report should contain:
- Patient name and identification number
- Name of laboratory
- Name of physician or practitioner ordering the test
- Date and time of the collected specimen, and date and time of receipt
- Reason for an unsatisfactory specimen, if applicable
- Test or evaluation performed
- Date and time of report
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