Physician orders for laboratory tests


West Point, CA
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Clinic is stating they placed an order for urinalysis 'digitally' so they don't need to submit documentation for the UA. I'm unable to code it as there is no diagnosis or intent for the procedure indicated. What are the documentation requirements for a physician ordered laboratory test? Shouldn't there be a document in the medical record that corresponds to the 'digital' order?


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Hi, this is an old thread, but I have similar questions. I wanted to ask are the following 'internal' policy questions or 'required by CMS type policy'. I am embarrassed of myself for asking these:
1) IF a provider puts in an e-order, but I don't see a signature OR any dx, but I see on a note prior whereby they mention "xyz test for xyz dx" (the "intent" (to me) was mentioned on the office note on a different DOS when they 'ordered' test) - Is it 'legal' for me to use that dx (from a prior DOS note) (Or is this an internal policy issue)? (and I document everything of where I got what ('i.e. dx from note dated 1/1/2020'), did what and why).
2) Having a difficult time 'policy' wise in organization and I don't want to be involved in any FCA suits.
3) RE: Outside providers (those who do not have access to the EMR and submit paper orders) - I do wait for those orders to be scanned in chart before appending 'their' dx's.
IF I see on paper order by outside provider 3-tests (i.e. CBC, CMP, Vit D), but I see the lab did 5-tests (CBC, CMP, Vit D, Lipid, TSH) - I 'wait' for the other tests order to be scanned in. IF no order for the extra tests done, to me, that is not good. We have no order, no notes, no 'intent' to order and to me that is bad. My thinking is these extra tests (w/o order, note) should be adjusted off before billing (the other tests) to insurance (the hospital/lab 'eats' the extra tests). I tried to read thru some MLN and CMS links, but honestly, I got lost in reading through it. I have no current (internal) instructions on how to handle these situations, but I am not releasing the claim to insurance. In meantime, the other 'legal/documented' tests are also not getting billed. I am attempting to get some manager of sort to answer these questions, but in meantime, here I am.
Question - Am I of right mind to be thinking what I said in # 3 above? Re-reading it, it 'sounds' completely legit thinking. IF a manager says "No, release as-is" I don't want to personally do something that is illegal, just because my 'super' tells me to.
4) and lastly - Outside provider on paper order is for PSA -Diagnostic (84153 w/dx of R97.20)- Lab for some reason (!?) does a PSA - Screening test (G0103). I am working these based on what my 'super' told me to do, but is it even 'correct' to bill a PSA Screen if provider ordered a PSA Diagnostic? Similar to #3 above, it is a different test (apparently the 'same' test lab-work wise (?), but is not CPT/payment wise). I cant wrap my head around this and am afraid I am doing something illegal.
Thank you for your time and consideration in answering these questions. Birdie