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December 16, 2011

Documentation Related to Diagnostic Tests

CGS is seeing an increase in the number of errors related to diagnostic services due to insufficient documentation. When submitting documentation please remember to include:

  • Order (while a physician's order is not required to be signed, he/she must clearly document in the medical record his/her intent that the test be performed
  • Properly SIGNED interpretation of the service
  • Medical Necessity of Services
    • No Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
    • Medical necessity is evidenced not only by correct ICD-9 coding but also by clinical documentation in the patient's medical record supporting the diagnosis and the need for the test
  • If subsequent or repeat testing is required, documentation must support the reasons why the initial tests were insufficient or why the serial progression of the test was required (i.e. CT first then MRI).

The Code of Federal Regulations, Title 42: Public Health 410.32 states, in part:

Diagnostic X-ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests

Ordering diagnostic tests: All diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests must be ordered by the physician who is treating the beneficiary, that is, the physician who furnishes a consultation or treats a 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 (see 411.15(k)(1) of this chapter).

Medical necessity: The entity submitting the claim may request additional diagnostic and other medical information from the ordering physician or nonphysician practitioner to document that the services it bills are reasonable and necessary. If the entity requests additional documentation, it must request material relevant to the medical necessity of the specific test(s), taking into consideration current rules and regulations on patient confidentiality.

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