Ancillary Lab/Xray order documentation requirements

mantlaua

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A patient was seen in the provider clinic and labs were ordered (CMP, CBC, Thyroxine, TSH and lipid) for diagnosis of abnormal findings in lung field. The labs are provided and billed through the hospital outpatient ancillary services. What areas in the clinic documentation can be used to code a medically necessary diagnosis when the clinic note assessment an diagnosis do not support medical necessity. The HPI, Exam, assessment and plan do not support order intent or medical necessity. The only place in the clinic note is the chronic conditions that patient has hyperlipidemia and hyperthyroidism. The medications list show medications to correspond with these diagnoses.

We received a denial for the thyroid and lipid test as not medically necessary as the only diagnosis documented on order and in note assessment for the labs ordered was abnormal findings of lung fields . We have difference of opinions. I think if the provider documented those diagnoses in the assessment even if not specifically linked to each specific test I would feel more comfortable coding that diagnosis but since it was not my thought is that coder should not assume a diagnosis as reason for a test when only documented in the chronic problem list when there is no documentation in the record (i.e. HPI, ROS, Exam, Assessment, or Plan) but rather query the provider and ask that the order or clinic not be amended to document the intent of order/medical necessity. Below and attached are a couple of documents from CMS Medicare Learning Network.

What is your opinion or process? Can the coder assume and code from soley from the chronic conditions/problem list as the reason the tests were ordered when the provider did not document in the note the intent and medical necessity of the services ordered?

CMS MLN Provider compliance tips for laboratory tests- other February 2018
ORDERS An order may be delivered via the following forms of communication:
• A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility. Although no signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services, documentation in the medical record must show intent to order and medical necessity for the testing.
• A telephone call by the treating physician/practitioner or his/her office to the testing facility.
• An electronic mail by the treating physician/practitioner or his/her office to the testing facility. If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary’s medical records. While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed.

CMS MLN August 2018
● 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 services
Documentation Requirements
● The physician who treats a beneficiary must order all diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests for a specific medical problem. The physician uses the results to manage the beneficiary’s specific medical problem and may furnish a consultation. Tests not ordered by the physician are not considered reasonable and necessary.
● The physician should clearly indicate all tests to be performed (for example, “run labs” or “check blood” by itself does not support intent to order) when completing progress notes.
● Documentation in the patient’s medical record must support the medical necessity for ordering the service(s) per Medicare regulations and applicable Local Coverage Determinations (LCDs). Submit these medical records if they are requested.
● Keep these records available to submit upon request: Progress notes or office notes Physician order or intent to order For more information about signature requirements and attestation statements, refer to the Medicare Simplifying Documentation Requirements webpage or Complying with Medicare Signature Requirements. Complying with Documentation Requirements for Laboratory Services MLN Fact Sheet Page 2 of 4 ICN 909221 August 2018 Laboratory results Attestation or signature log for illegible signature(s)
 

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