Pathology/Lab Coding Alert

Fill holes in documentation.

Lab test orders are one area that frequently caused errors during Medicare processing in 2021. That’s the word from the latest Comprehensive Error Rate testing (CERT) report from the Centers for Medicare and Medicaid Services (CMS).

That key piece of advice was shared by CGS Medicare’s Julene Lienard during a recent Part B payer’s webinar “Top CERT Errors for 2021.” Read on for details you need to know.

Tip: Labs can minimize order errors by educating physician clients and by upgrading test-order procedures and forms.

Error 1: Inadequate Documentation for Diagnostic Lab Tests

Documentation for lab tests fell short frequently enough that this ranked atop the list of Part B errors that CGS has seen so far in 2021, Lienard said. “These were inadequate due to missing documentation,” she noted. “For instance, one claim was missing the treating physician’s order; … [another] claim was missing the clinical documentation to support the medical necessity; … [another] claim didn’t identify the beneficiary.”

The physician’s documentation reveals the information that should be in the lab order to support medical necessity, Lienard added. “You always want to make sure you get that note from the treating physician as to why they want these tests run.”

If your lab order has check boxes where the physician can check off the ICD-10 codes, that isn’t typically sufficient to demonstrate medical necessity for the service, she noted. “They would also need to have the physician write out the reason that he wants these services performed. You can put a little comment section on your order form if that’s what you’re using.” Whether you’re operating with hand-written or electronic orders, labs should have a place for the physician to document the reason for the test with a narrative description.

Error 2: Missing Documentation That Would Support Service Frequency

In some cases, Medicare has frequency guidelines that limit how often you can bill for a service or order a particular diagnostic test. These guidelines may also have limitations on what other criteria you must meet before you can administer a particular service or order a test, such as patient age. In certain circumstances, your documentation must support exceeding frequency guidelines, but many claims are missing that information, Lienard noted.

For example: If the physician orders a definitive drug tests (G0483, Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers …), the insurer may be looking for clinical documentation to support the fact that the beneficiary has abstained for 31 to 90 days, Lienard said. Without that documentation, your claim for this service might be denied. “We do see quite a few of these,” she said.

Error 3: Using Out-of-Date Guidelines

When reviewers look at your documentation, they’re matching it against the guidelines that were in place on the date of service. If they’re reviewing claims with a date of service from 2019, they will look at retired local coverage determinations (LCDs) that were in place at the time of service, and not the LCDs that are in place today, Lienard added.

Key: If you don’t keep up with guideline updates, you could be filing claims under old rules that don’t apply. On the flip side, if you’re filing a claim long after the service date, you can’t go by current guidelines that might have changed since your lab performed the service.