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:

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  • 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
  • Result
  • Date and time of report
John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 402 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

10 Responses to “Proper Documentation for Pathology and Laboratory Reports”

  1. Lorraine Papazian-Boyce says:

    Can you point us to the reference source for this information? Thanks.

  2. Lucinda Hurley says:

    Please provide a reference source for the information cited in ‘Proper Documentation for Pathology and Laboratory Reports’.

    Thank you

  3. Renee Niquette says:

    Please provide a reference source for the information cited in ‘Proper Documentation for Pathology and Laboratory Reports’. Thank you

  4. Diane Turner says:

    I agree that there should be a reference source for this information. Most providers want to see that before they will start documenting like this says.

  5. MaryAnne Heath says:

    I would also like to see a reference source for this information, particularly “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”. Thank you.

  6. Lorraine Papazian-Boyce says:

    I sent a request to AAPC Customer Service to provide us with this info, because they do not monitor these comments on a regular basis. I will share any info they send back unless they post here instead.

  7. John Verhovshek says:

    Hello All,

    This is John Verhovshek, author of the article.

    The recommendations in the article are not from a single source, but rather represent “best practices” as culled from a variety of recommendations and reports.

    I have never seen, or been able to find, comprehensive guidelines from either the AMA or CMS to describe the required contents of a pathology report. The introduction of the CPT® codebook says only, “Reports are the work product of the interpretation of test results…. Some CPT descriptors specifically require interpretation and reporting to report that code.”

    Lacking clear guidelines from CPT® or payers, providers must rely on recommendations from advocacy and academic groups, or their own best judgment. To cite just one example, the National Cancer Institute (http://www.cancer.gov/cancertopics/factsheet/detection/pathology-reports) defines the contents of a pathology report usually to include:

    • Patient information: Name, birth date, biopsy date
    • Gross description: Color, weight, and size of tissue as seen by the naked eye
    • Microscopic description: How the sample looks under the microscope and how it compares with normal cells
    • Diagnosis: Type of tumor/cancer and grade (how abnormal the cells look under the microscope and how quickly the tumor is likely to grow and spread)
    • Tumor size: Measured in centimeters
    • Tumor margins: There are three possible findings when the biopsy sample is the entire tumor:
    o Positive margins mean that cancer cells are found at the edge of the material removed
    o Negative, not involved, clear, or free margins mean that no cancer cells are found at the outer edge
    o Close margins are neither negative nor positive
    • Other information: Usually notes about samples that have been sent for other tests or a second opinion
    • Pathologist’s signature and name, and address of the laboratory

    There are a variety of other, more extensive recommendations, including “Reporting Guidelines for Clinical Laboratory Reports in Surgical Pathology” (http://www.archivesofpathology.org/doi/pdf/10.1043/1543-2165(2008)132%5B1608%3ARGFCLR%5D2.0.CO%3B2) and the Commission on Laboratory Accreditation “Anatomic Pathology Checklist” (http://www.cap.org/apps/docs/laboratory_accreditation/checklists/anatomic_pathology_Sep07.pdf). These generally go much further, but allow for greater flexibility and variation in the contents of the report, depending on the nature of the test.

    Providers are (reasonably) resistant to “over document” services or to spend time on unnecessary paperwork, but the report is a crucial element. Without it, one might argue that there is no solid evidence that the test was medically necessary. If the results of the test aren’t worth explanation and reporting, and/or don’t factor into the plan of care, why should anyone pay for it?

    Although no payer guidelines specifically cite these requirements, this is why I wrote, “the physician must note the type of test, the methodology used, the normal range for the test, and 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.” The point is to show that the results are/were relevant to patient treatment, and therefore are reasonable and necessary.

    Although payers typically won’t require that a report be submitted, when billing, in the event of an audit, the report/documentation should be available, just as you would need to maintain documentation to support billing with a modifier, for instance. If the documentation is insufficient (or nonexistent), you can expect trouble. I was recently advised of a case in which a provider billing for in-office pathology was not writing reports, with the justification that he (and ostensibly, any other provider) could reference the test results at any time and learn whatever he needed to know. This was discovered during a payer audit, and now that payer is asking for repayment for every test billed without a report—a very bad situation.

    Here’s another wrinkle, although it’s not immediately relevant: Federal law now requires that patients have direct access to lab results. See here: https://www.federalregister.gov/articles/2014/02/06/2014-02280/clia-program-and-hipaa-privacy-rule-patients-access-to-test-reports?utm_campaign=pi+subscription+mailing+list&utm_medium=email&utm_source=federalregister.gov#h-21

    You can also read a pretty good summary of the rule, here: http://www.healthlawpolicymatters.com/2014/02/04/cms-finalizes-hipaa-and-clia-amendments-intended-to-increase-patient-access-to-test-results/

    The law does not require that the lab interpret the results for the patient, but I would assume that if the provider billing for the lab service is also the patient’s treating provider, he or she would discuss the “raw” results with the patient.

    I do hope this information helps!

    -John

  8. Joan Gilhooly says:

    I’m not from AAPC customer service, but just became aware of this thread this morning and felt it imperative to respond to the horrific misinformation contained in this article. Speaking as a medical technologist and a certified coder (and E/M expert), most of the information in this article is flat out wrong.

    #1 below is the only thing I agreed with from the article. #2-6 are the ones I disagreed with (and why).

    (1) There does need to be a signed order from the physician for the lab test. It can be a separate document (or ordered under the “Orders” tab in an EMR) or the intent to order the tests can be documented in the physician’s signed progress note. Btw, this applies to tests performed outside of the office, AS WELL AS tests performed within the office (Authoritative reference: Pub 100-8, Chapter 3, Section 3.3.4.2)

    (2) Re: documentation of medical necessity for these laboratory tests — and how the physician used the tests in the diagnosis and treatment of the patient does NOT need to be explicitly documented. According to both the 95 and 97 Documentation Guidelines, “…..the rational for ordering diagnostic and other ancillary services should be easily inferred” (Authoritative reference: 95 and 97 Documentation Guidelines, #3 under General Principles of Medical Record Documentation” found in the Introduction section of the Documentation Guidelines”.

    By “readily inferred”, that doesn’t mean readily inferred by a coder who is untrained in laboratory medicine, though. That means that if another physician — who understands what test are needed — can look at the documentation and infer why the tests were ordered, the standard has been met. For any coder who is questioning whether a particular test was medically necessary, ask a physician to take a look at the progress note — and if he/she says they can see why that test was ordered, then the criteria has been met.

    (3) As for what needs to be presented as “proof” that the lab test had been performed, the writer is confusing what is standard documentation for tests performed by outside labs where that information is included on the report for reasons that have ABSOLUTELY NOTHING TO DO with reimbursement. Even tests performed by outside labs do NOT report the test methodology used on their reports unless that methodology could have potential clinical implications for the physician. For tests performed in-house, the physicians already know what test kits they bought for these tests to be performed, so separate reporting of that on the actual results in unnecessary.

    (4) “…..It is not sufficient to copy that number value into the patient’s chart or attach the computer printout to the patient record”.

    Another falsehood. Proof that the test was performed is whether or not test results are documented. A computer printout from the instrument (for those that are done on an instrument that is hooked to a printer) is absolutely proof that the test was performed.

    And for tests that are performed manually or on instruments that are NOT hooked up to a printer? There simply needs to be documentation of what test was performed and what the result was that was obtained.

    (as an aside, I had this issue come up in an appeal for a ZPIC audit for a client of mine a couple of years ago. When our appeal was reviewed at the QIC level, the QIC agreed with us that a printout wasn’t required as proof the test was done. They accepted the values as recorded in the physician’s EMR progress note as proof that the test had been performed.)

    AUTHORITATIVE REFERENCE: 42 CFR 424.5 (a)(6) which in essence says that the provider must be able to present sufficient evidence that the service billed was actually performed. As demonstrated with the QIC review above, CMS is in agreement that the lab test result is sufficient proof that the test was performed.

    (5) “…… 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…..”

    There are several issues with this. First, for outside labs, the test results often come back days after the physician has completed the notes. So there’s no way to “address the abnormality in the diagnosis and treatment plan” in a note that was completed at the time of service! And please don’t think that the physician is required to go back and amend the notes. There’s absolutely NOTHING in any guidance from CMS or the AMA that would even imply this.

    Secondly, while one component of medical necessity for laboratory testing is evidence that the physician needed this information in their treatment of the patient, “circling and signing” an abnormal test result has ZERO to do with reimbursement for the testing — or even for medical necessity for having ordered it in the first place. That may be a clinical “best practices” recommendation by a malpractice carrier — and frankly, I’m not disagreeing with it being a SUGGESTION for how to make sure that results that are abnormal enough to be addressed are actually addressed. But another thing that the writer doesn’t realize is that those normal ranges are based on the fact that 95% +/- 2 standard deviations of a “healthy” population fall within those ranges. That means, by definition, 5% of the normal population will have an “abnormal” test RESULT that is NOT *clinically abnormal*.

    (6) The 8 elements the writer listed as “must haves” on the laboratory results report are ones that are typically found in a report for testing performed by an outside laboratory.

    There’s nothing that says that this information must also be included for any tests performed in-house, especially for those that are designed to be point-of-care style tests. If the doctor orders a random glucose to be performed in the exam room on the practice’s hand-held glucometer (CPT code 82962), it’s perfectly OK to record that test result in the physician’s progress notes for that patient without having to separately list the other 6 elements that the author claims “must” be present in a valid laboratory report.

    (same Code of Federal Regulations citation that I mentioned above)

    Given that it’s now a month after this article was written, I have no idea whether any of you will be coming back to see if AAPC had responded. I’m going to send them an email and ask them to issue a retraction because there was so much false or misleading information in this article. Keeping my fingers crossed that they agree to do so.

  9. MaryAnne Heath says:

    Thank you Joan Gilhooly – I have been checking back periodically as I would like to see AAPC’s response and haven’t seen any kind of email regarding this article. And thank you and Lorraine for emailing customer service. I will continue to check back here unless I hear something from AAPC in the meantime.

  10. Lorraine Papazian-Boyce says:

    PS Joan, The link to the article was sent out via Healthcare Business: Tips and Resources e-mail on 7/7/14 and all the posts have been since then, so hopefully people will check back.

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