Documentation Requirements for Diagnostic Tests

on Tuesday, 16 July 2019. All News Items | Outpatient Services | Documentation

Back to the Basics

Sometimes providers do not pay as much attention to the Medicare documentation requirements for diagnostic tests as they do for therapeutic services. There are several reasons for this. Diagnostic tests generally do not pay as much as therapeutic services, they are less likely to have a coverage policy, the documentation required is not as extensive as the documentation requirements for therapeutic services, and they are less likely to be reviewed by Medicare contractors. Therefore, the financial risk, even if some claims are reviewed, is not that significant for an individual provider. For Medicare however, due to the large volumes of diagnostic services, overpayments could result in significant costs.

The Medicare Comprehensive Error Rate Testing (CERT) program contractor audits random claims to determine if the Medicare Administrative Contractors (MACs) are paying claims appropriately. This means the CERT contractor looks at all types of claims, including those for diagnostic tests. WPS, the MAC for Jurisdictions 5 and 8, recently published an article containing documentation reminders related to CERT denials of diagnostic tests. Those documentation reminders are:

  • “Only the treating physician, nurse practitioner, clinical nurse specialist or physician assistant can sign and date an order.
  • The order must specify the exact test(s) ordered. Stating “x-ray” is not sufficient.
  • The physician or non-physician must document the medical necessity in a signed and dated progress note.
  • Medicare will not consider unsigned and/or undated orders; this includes laboratory requisition forms.
  • Providers cannot use a signature attestation statement used in place of an unsigned order.”

These are the basics of which every provider should already be aware. But the article states the CERT contractor has “noted significant error findings for diagnostic services.” So, where do providers go wrong? First, nurses in a physician’s office cannot sign an order. Physicians and non-physician practitioners may delegate the writing of orders to others in the office, but they have to actually be the ones to validate and sign the orders. Remember that Medicare contractors do not accept late signatures or signature attestations for orders. Unsigned orders are “ignored” by Medicare reviewers – an unsigned order is the same as a non-existent order. Orders and progress notes describing the orders must be specific – for example, a progress note that states “labs ordered” or “x-rays ordered” is not sufficient.

The other big issue for diagnostic tests besides signed and dated orders is documentation supporting the medical necessity of the test. Years ago, if you had a signed and dated order that included a diagnosis or a diagnosis code, that was sufficient for medical necessity. These days, most Medicare reviewers want to also see the documentation from the physician, such as an office progress note, describing the medical necessity for the test. And remember any physician progress notes submitted to a Medicare contractor also have to be signed and dated by the practitioner. The good thing about CERT reviews is that the CERT contractor generally communicates the need for any additional documentation needed and gives the provider several chances to submit that before denying the claim.

Some other diagnostic services are also being targeted by other Medicare reviewers and entities. For example, Novitas (JH/JL MAC) is looking at cardiovascular nuclear medicine testing, sleep testing is part of the OIG Work Plan, and the Recovery Auditors (RACs) have complex reviews involving the medical necessity/coding of chest x-rays and the medical necessity of transthoracic echocardiography.

One new complex issue recently approved by all of the Recovery Auditors is for the diagnostic test Computed Tomography (CT) Coronary Angiography. The issue details reiterate the documentation reminders discussed above -

“All diagnostic tests, including Computed Tomography (CT) Coronary Angiography, must be ordered by the physician who is treating the beneficiary, for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. The physician who orders the service must maintain documentation of medical necessity in the beneficiary's medical record. Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, as part of a routine physical checkup are excluded from coverage.”

How can hospitals ensure compliance with the signature and medical necessity requirements of diagnostic tests without undue effort? Train hospital personnel who first encounter orders for diagnostic testing to reject or obtain corrected orders when order requirements are not met – unsigned orders, orders not dated, orders lacking diagnoses, non-specific orders, etc. This could be the Scheduling, Registration, or Ancillary departments, for example. Hopefully, the practice of only accepting appropriate orders will encourage your physicians and practitioners to get it right the first time. On the back end, if a Medicare reviewer requests claims for diagnostic tests ensure all the required documentation is sent to the reviewer. The request for records should detail the specific medical record elements the reviewer needs. If required, contact the ordering physician’s office to obtain office progress notes for submission to the Medicare contractor.

With a little effort, denials of diagnostic tests can be eliminated or at least, minimized. Though not always a large financial impact, every penny helps and proactive processes also reduce the costs of additional time and effort.

There are no MAC Medical Review Activity updates for this month.

Another good resource for Providers is the CMS YouTube presentation Provider Minute: The Importance of Proper Documentation at https://www.youtube.com/watch?v=10pmw4czf08.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc.  Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system.  In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.  You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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